Sample records for error management lessons

  1. Lessons Learned the Hard Way but Learned Well

    ERIC Educational Resources Information Center

    Dirksen, Debra J.

    2014-01-01

    The author spins a tale of how she learned classroom management largely by trial and error and by making a commitment to never give up on her students. Classroom management done well provides the signposts that give students direction and enables them to reach their destination as learners and human beings. Classroom management is one of the most…

  2. Intelligent Embedded Instruction for Computer-Aided Design (CAD) systems

    DTIC Science & Technology

    1988-10-01

    difficulties were predicted and six lessons were prepared that were aimed at preventing error pattern formation. The lessons were programmed in AUTOLISP ...and arcs, angles of lines, layering (linetype and color), and block creation and insertion. A program written in AUTOLISP examined the values in the...One site had AutoCAD reference manuals nearby and others had no manuals . * Only one site set a schedule for the users. * The attitudes of managers

  3. Missed opportunities for diagnosis: lessons learned from diagnostic errors in primary care.

    PubMed

    Goyder, Clare R; Jones, Caroline H D; Heneghan, Carl J; Thompson, Matthew J

    2015-12-01

    Because of the difficulties inherent in diagnosis in primary care, it is inevitable that diagnostic errors will occur. However, despite the important consequences associated with diagnostic errors and their estimated high prevalence, teaching and research on diagnostic error is a neglected area. To ascertain the key learning points from GPs' experiences of diagnostic errors and approaches to clinical decision making associated with these. Secondary analysis of 36 qualitative interviews with GPs in Oxfordshire, UK. Two datasets of semi-structured interviews were combined. Questions focused on GPs' experiences of diagnosis and diagnostic errors (or near misses) in routine primary care and out of hours. Interviews were audiorecorded, transcribed verbatim, and analysed thematically. Learning points include GPs' reliance on 'pattern recognition' and the failure of this strategy to identify atypical presentations; the importance of considering all potentially serious conditions using a 'restricted rule out' approach; and identifying and acting on a sense of unease. Strategies to help manage uncertainty in primary care were also discussed. Learning from previous examples of diagnostic errors is essential if these events are to be reduced in the future and this should be incorporated into GP training. At a practice level, learning points from experiences of diagnostic errors should be discussed more frequently; and more should be done to integrate these lessons nationally to understand and characterise diagnostic errors. © British Journal of General Practice 2015.

  4. Crew resource management: applications in healthcare organizations.

    PubMed

    Oriol, Mary David

    2006-09-01

    Healthcare organizations continue their struggle to establish a culture of open communication and collaboration. Lessons are learned from the aviation industry, which long ago acknowledged that most errors were the result of poor communication and coordination rather than individual mistakes. The author presents a review of how some healthcare organizations have successfully adopted aviation's curriculum called Crew Resource Management, which promotes and reinforces the conscious, learned team behaviors of cooperation, coordination, and sharing.

  5. Handling Errors as They Arise in Whole-Class Interactions

    ERIC Educational Resources Information Center

    Ingram, Jenni; Pitt, Andrea; Baldry, Fay

    2015-01-01

    There has been a long history of research into errors and their role in the teaching and learning of mathematics. This research has led to a change to pedagogical recommendations from avoiding errors to explicitly using them in lessons. In this study, 22 mathematics lessons were video-recorded and transcribed. A conversation analytic (CA) approach…

  6. Lessons from Crew Resource Management for Cardiac Surgeons.

    PubMed

    Marvil, Patrick; Tribble, Curt

    2017-04-30

    Crew resource management (CRM) describes a system developed in the late 1970s in response to a series of deadly commercial aviation crashes. This system has been universally adopted in commercial and military aviation and is now an integral part of aviation culture. CRM is an error mitigation strategy developed to reduce human error in situations in which teams operate in complex, high-stakes environments. Over time, the principles of this system have been applied and utilized in other environments, particularly in medical areas dealing with high-stakes outcomes requiring optimal teamwork and communication. While the data from formal studies on the effectiveness of formal CRM training in medical environments have reported mixed results, it seems clear that some of these principles should have value in the practice of cardiovascular surgery.

  7. Lessons to be Learned from Evidence-based Medicine: Practice and Promise of Evidence-based Medicine and Evidence-based Education.

    ERIC Educational Resources Information Center

    Wolf, Fredric M.

    2000-01-01

    Presents statistics of deaths caused by medical errors and argues the effects of misconceptions in diagnosis and treatment. Suggests evidence-based medicine to enhance the quality of practice and minimize error rates. Presents 10 evidence-based lessons and discusses the possible benefits of evidence-based medicine to evidence-based education and…

  8. Measurement error in performance studies of health information technology: lessons from the management literature.

    PubMed

    Litwin, A S; Avgar, A C; Pronovost, P J

    2012-01-01

    Just as researchers and clinicians struggle to pin down the benefits attendant to health information technology (IT), management scholars have long labored to identify the performance effects arising from new technologies and from other organizational innovations, namely the reorganization of work and the devolution of decision-making authority. This paper applies lessons from that literature to theorize the likely sources of measurement error that yield the weak statistical relationship between measures of health IT and various performance outcomes. In so doing, it complements the evaluation literature's more conceptual examination of health IT's limited performance impact. The paper focuses on seven issues, in particular, that likely bias downward the estimated performance effects of health IT. They are 1.) negative self-selection, 2.) omitted or unobserved variables, 3.) mis-measured contextual variables, 4.) mismeasured health IT variables, 5.) lack of attention to the specific stage of the adoption-to-use continuum being examined, 6.) too short of a time horizon, and 7.) inappropriate units-of-analysis. The authors offer ways to counter these challenges. Looking forward more broadly, they suggest that researchers take an organizationally-grounded approach that privileges internal validity over generalizability. This focus on statistical and empirical issues in health IT-performance studies should be complemented by a focus on theoretical issues, in particular, the ways that health IT creates value and apportions it to various stakeholders.

  9. Energy Management Lesson Plans for Vocational Agriculture Instructors.

    ERIC Educational Resources Information Center

    Hedges, Lowell E., Ed.; Miller, Larry E., Ed.

    This notebook provides vocational agricultural teachers with 10 detailed lesson plans on the major topic of energy management in agriculture. The lesson plans present information about energy and the need to manage it wisely, using a problem-solving approach. Each lesson plan follows this format: lesson topic, lesson performance objectives,…

  10. Applying lessons from social psychology to transform the culture of error disclosure.

    PubMed

    Han, Jason; LaMarra, Denise; Vapiwala, Neha

    2017-10-01

    The ability to carry out prompt and effective error disclosure has been described in the literature as an essential skill among physicians that can lead to improved patient satisfaction, staff well-being and hospital outcomes. However, few studies have addressed the social psychology principles that may influence physician behaviour. The authors provide an overview of recent administrative measures designed to encourage physicians to disclose error, but note that deliberate practice, buttressed with lessons from social psychology, is needed to implement further productive behavioural changes. Two main cognitive biases that may hinder error disclosure are identified, namely: fundamental attribution error, and forecasting error. Strategies to overcome these maladaptive cognitive patterns are discussed. The authors note that interactions with standardised patients (SPs) can be used to simulate hospital encounters and help teach important behavioural considerations. Virtual reality is introduced as an immersive, realistic and easily scalable technology that can supplement traditional curricula. Lastly, the authors highlight the importance of establishing a professional standard of competence, potentially by incorporating difficult patient encounters, including disclosure of error, into medical licensing examinations that assess clinical skills. Existing curricula that cover physician error disclosure may benefit from reviewing the social psychology literature. These lessons, incorporated into SP programmes and emerging technological platforms, may improve training and evaluative methods for all medical trainees. © 2017 John Wiley & Sons Ltd and The Association for the Study of Medical Education.

  11. Organizational Dysfunction in the US Air Force: Lessons from the ICBM Community

    DTIC Science & Technology

    2016-06-01

    separated the space and missile career fields, highlighting a need to produce career professionals in the ICBM community.12 During this time, errors...raises for missileers,” Air Force Times 74, no. 29 (27 Jan, 2014): 10. 20 Gen Martin Dempsey, “America’s Military – A Profession of Arms.” Washington...Bullying”, 18-20; Cynthia Coccia, "Avoiding a "Toxic" Organization," Nursing Management 29, no. 5 (May 1998): 32; Janie Fritz. “Organizational Misbehavior

  12. Mars Exploration Rover Potentiometer Problems, Failures and Lessons Learned

    NASA Technical Reports Server (NTRS)

    Balzer, Mark

    2006-01-01

    During qualification testing of three types of non-wire-wound precision potentiometers for the Mars Exploration Rover, a variety of problems and failures were encountered. This paper will describe some of the more interesting problems, detail their investigations and present their final solutions. The failures were found to be caused by design errors, manufacturing errors, improper handling, test errors, and carelessness. A trend of decreasing total resistance was noted, and a resistance histogram was used to identify an outlier. A gang fixture is described for simultaneously testing multiple pots, and real time X-ray imaging was used extensively to assist in the failure analyses. Lessons learned are provided.

  13. Mars Exploration Rover potentiometer problems, failures and lessons learned

    NASA Technical Reports Server (NTRS)

    Balzer, Mark A.

    2006-01-01

    During qualification testing of three types of nonwire-wound precision potentiometers for the Mars Exploration Rover, a variety of problems and failures were encountered. This paper will describe some of the more interesting problems, detail their investigations and present their final solutions. The failures were found to be caused by design errors, manufacturing errors, improper handling, test errors, and carelessness. A trend of decreasing total resistance was noted, and a resistance histogram was used to identify an outlier. A gang fixture is described for simultaneously testing multiple pots, and real time X-ray imaging was used extensively to assist in the failure analyses. Lessons learned are provided.

  14. Medical informatics in medical research - the Severe Malaria in African Children (SMAC) Network's experience.

    PubMed

    Olola, C H O; Missinou, M A; Issifou, S; Anane-Sarpong, E; Abubakar, I; Gandi, J N; Chagomerana, M; Pinder, M; Agbenyega, T; Kremsner, P G; Newton, C R J C; Wypij, D; Taylor, T E

    2006-01-01

    Computers are widely used for data management in clinical trials in the developed countries, unlike in developing countries. Dependable systems are vital for data management, and medical decision making in clinical research. Monitoring and evaluation of data management is critical. In this paper we describe database structures and procedures of systems used to implement, coordinate, and sustain data management in Africa. We outline major lessons, challenges and successes achieved, and recommendations to improve medical informatics application in biomedical research in sub-Saharan Africa. A consortium of experienced research units at five sites in Africa in studying children with disease formed a new clinical trials network, Severe Malaria in African Children. In December 2000, the network introduced an observational study involving these hospital-based sites. After prototyping, relational database management systems were implemented for data entry and verification, data submission and quality assurance monitoring. Between 2000 and 2005, 25,858 patients were enrolled. Failure to meet data submission deadline and data entry errors correlated positively (correlation coefficient, r = 0.82), with more errors occurring when data was submitted late. Data submission lateness correlated inversely with hospital admissions (r = -0.62). Developing and sustaining dependable DBMS, ongoing modifications to optimize data management is crucial for clinical studies. Monitoring and communication systems are vital in multi-center networks for good data management. Data timeliness is associated with data quality and hospital admissions.

  15. Magellan spacecraft and memory state tracking: Lessons learned, future thoughts

    NASA Technical Reports Server (NTRS)

    Bucher, Allen W.

    1993-01-01

    Numerous studies have been dedicated to improving the two main elements of Spacecraft Mission Operations: Command and Telemetry. As a result, not much attention has been given to other tasks that can become tedious, repetitive, and error prone. One such task is Spacecraft and Memory State Tracking, the process by which the status of critical spacecraft components, parameters, and the contents of on-board memory are managed on the ground to maintain knowledge of spacecraft and memory states for future testing, anomaly investigation, and on-board memory reconstruction. The task of Spacecraft and Memory State Tracking has traditionally been a manual task allocated to Mission Operations Procedures. During nominal Mission Operations this job is tedious and error prone. Because the task is not complex and can be accomplished manually, the worth of a sophisticated software tool is often questioned. However, in the event of an anomaly which alters spacecraft components autonomously or a memory anomaly such as a corrupt memory or flight software error, an accurate ground image that can be reconstructed quickly is a priceless commodity. This study explores the process of Spacecraft and Memory State Tracking used by the Magellan Spacecraft Team highlighting its strengths as well as identifying lessons learned during the primary and extended missions, two memory anomalies, and other hardships encountered due to incomplete knowledge of spacecraft states. Ideas for future state tracking tools that require minimal user interaction and are integrated into the Ground Data System will also be discussed.

  16. Magellan spacecraft and memory state tracking: Lessons learned, future thoughts

    NASA Astrophysics Data System (ADS)

    Bucher, Allen W.

    1993-03-01

    Numerous studies have been dedicated to improving the two main elements of Spacecraft Mission Operations: Command and Telemetry. As a result, not much attention has been given to other tasks that can become tedious, repetitive, and error prone. One such task is Spacecraft and Memory State Tracking, the process by which the status of critical spacecraft components, parameters, and the contents of on-board memory are managed on the ground to maintain knowledge of spacecraft and memory states for future testing, anomaly investigation, and on-board memory reconstruction. The task of Spacecraft and Memory State Tracking has traditionally been a manual task allocated to Mission Operations Procedures. During nominal Mission Operations this job is tedious and error prone. Because the task is not complex and can be accomplished manually, the worth of a sophisticated software tool is often questioned. However, in the event of an anomaly which alters spacecraft components autonomously or a memory anomaly such as a corrupt memory or flight software error, an accurate ground image that can be reconstructed quickly is a priceless commodity. This study explores the process of Spacecraft and Memory State Tracking used by the Magellan Spacecraft Team highlighting its strengths as well as identifying lessons learned during the primary and extended missions, two memory anomalies, and other hardships encountered due to incomplete knowledge of spacecraft states. Ideas for future state tracking tools that require minimal user interaction and are integrated into the Ground Data System will also be discussed.

  17. What went right: lessons for the intensivist from the crew of US Airways Flight 1549.

    PubMed

    Eisen, Lewis A; Savel, Richard H

    2009-09-01

    On January 15, 2009, US Airways Flight 1549 hit geese shortly after takeoff from LaGuardia Airport in New York City. Both engines lost power, and the crew quickly decided that the best action was an emergency landing in the Hudson River. Due to the crew's excellent performance, all 155 people aboard the flight survived. Intensivists can learn valuable lessons from the processes and outcome of this incident, including the importance of simulation training and checklists. By learning from the aviation industry, the intensivist can apply principles of crew resource management to reduce errors and improve patient safety. Additionally, by studying the impact of the mandated process-engineering applications within commercial aviation, intensivists and health-care systems can learn certain principles that, if adequately and thoughtfully applied, may seriously improve the art and science of health-care delivery at the bedside.

  18. Clinical risk management in obstetrics.

    PubMed

    Holden, Deborah A; Quin, Maureen; Holden, Des P

    2004-04-01

    Over recent years there has been a growing appreciation that a small but significant proportion of patients experience (sometimes serious) adverse events in the hands of health care workers. Although research in this area is very much in its infancy there has been an increasing move towards applying principles of risk management from industry to health care organizations. With the particularly disastrous and costly nature of adverse outcomes in obstetrics it is appropriate to review clinical risk management issues in maternity. This review explores the appropriateness of applying lessons learned in industry to maternity. The classification of errors into individual and latent, or organizational, is examined. Furthermore, the way in which these errors can be identified and subsequently analysed, with examples from maternity units in the UK and USA, is discussed. The importance of an educational and supportive environment, rather than a blame culture, for both reporting of incidents and learning from adverse outcomes is emphasized. Improvement in patient experience of health care rests not just with improved treatments, but also with a reduction in the adverse events which occur in health care institutions. The principles by which risk can be identified prospectively and retrospectively, and the mechanisms for both local risk management and regional/national reporting and learning are considered.

  19. Human Factors Throughout the Life Cycle: Lessons Learned from the Shuttle Program. [Human Factors in Ground Processing

    NASA Technical Reports Server (NTRS)

    Kanki, Barbara G.

    2011-01-01

    With the ending of the Space Shuttle Program, it is critical that we not forget the Human Factors lessons we have learned over the years. At every phase of the life cycle, from manufacturing, processing and integrating vehicle and payload, to launch, flight operations, mission control and landing, hundreds of teams have worked together to achieve mission success in one of the most complex, high-risk socio-technical enterprises ever designed. Just as there was great diversity in the types of operations performed at every stage, there was a myriad of human factors that could further complicate these human systems. A single mishap or close call could point to issues at the individual level (perceptual or workload limitations, training, fatigue, human error susceptibilities), the task level (design of tools, procedures and aspects of the workplace), as well as the organizational level (appropriate resources, safety policies, information access and communication channels). While we have often had to learn through human mistakes and technological failures, we have also begun to understand how to design human systems in which individuals can excel, where tasks and procedures are not only safe but efficient, and how organizations can foster a proactive approach to managing risk and supporting human enterprises. Panelists will talk about their experiences as they relate human factors to a particular phase of the shuttle life cycle. They will conclude with a framework for tying together human factors lessons-learned into system-level risk management strategies.

  20. Attention to Form or Meaning? Error Treatment in the Bangalore Project.

    ERIC Educational Resources Information Center

    Beretta, Alan

    1989-01-01

    Reports on an evaluation of the Bangalore/Madras Communicational Teaching Project (CTP), a content-based approach to language learning. Analysis of 21 lesson transcripts revealed a greater incidence of error treatment of content than linguistic error, consonant with the CTP focus on meaning rather than form. (26 references) (Author/CB)

  1. Errors in veterinary practice: preliminary lessons for building better veterinary teams.

    PubMed

    Kinnison, T; Guile, D; May, S A

    2015-11-14

    Case studies in two typical UK veterinary practices were undertaken to explore teamwork, including interprofessional working. Each study involved one week of whole team observation based on practice locations (reception, operating theatre), one week of shadowing six focus individuals (veterinary surgeons, veterinary nurses and administrators) and a final week consisting of semistructured interviews regarding teamwork. Errors emerged as a finding of the study. The definition of errors was inclusive, pertaining to inputs or omitted actions with potential adverse outcomes for patients, clients or the practice. The 40 identified instances could be grouped into clinical errors (dosing/drugs, surgical preparation, lack of follow-up), lost item errors, and most frequently, communication errors (records, procedures, missing face-to-face communication, mistakes within face-to-face communication). The qualitative nature of the study allowed the underlying cause of the errors to be explored. In addition to some individual mistakes, system faults were identified as a major cause of errors. Observed examples and interviews demonstrated several challenges to interprofessional teamworking which may cause errors, including: lack of time, part-time staff leading to frequent handovers, branch differences and individual veterinary surgeon work preferences. Lessons are drawn for building better veterinary teams and implications for Disciplinary Proceedings considered. British Veterinary Association.

  2. Data quality assurance and control in cognitive research: Lessons learned from the PREDICT-HD study.

    PubMed

    Westervelt, Holly James; Bernier, Rachel A; Faust, Melanie; Gover, Mary; Bockholt, H Jeremy; Zschiegner, Roland; Long, Jeffrey D; Paulsen, Jane S

    2017-09-01

    We discuss the strategies employed in data quality control and quality assurance for the cognitive core of Neurobiological Predictors of Huntington's Disease (PREDICT-HD), a long-term observational study of over 1,000 participants with prodromal Huntington disease. In particular, we provide details regarding the training and continual evaluation of cognitive examiners, methods for error corrections, and strategies to minimize errors in the data. We present five important lessons learned to help other researchers avoid certain assumptions that could potentially lead to inaccuracies in their cognitive data. Copyright © 2017 John Wiley & Sons, Ltd.

  3. Opportunities to Notice: Chinese Prospective Teachers Noticing Students' Ideas in a Distance Formula Lesson

    ERIC Educational Resources Information Center

    Ding, Lin; Domínguez, Higinio

    2016-01-01

    This paper investigates the noticing of six Chinese mathematics prospective teachers (PSTs) when looking at a procedural error and responding to three specific tasks related to that error. Using video clips of one student's procedural error consisting of exchanging the order of coordinates when applying the distance formula, some variation was…

  4. "DOS for Managers." Management Training Series.

    ERIC Educational Resources Information Center

    Marion County Schools, Fairmont, WV.

    A plan is provided for a lesson on disk operating systems (DOS) for managers. Twenty-five lesson objectives are listed, followed by suggestions for learning activities and special resources. In the presentation section, key points and content are provided for 25 instructional topics that correspond to the 25 lesson objectives. The topics are as…

  5. Effect of tailored on-road driving lessons on driving safety in older adults: A randomised controlled trial.

    PubMed

    Anstey, Kaarin J; Eramudugolla, Ranmalee; Kiely, Kim M; Price, Jasmine

    2018-06-01

    We evaluated the effectiveness of individually tailored driving lessons compared with a road rules refresher course for improving older driver safety. Two arm parallel randomised controlled trial, involving current drivers aged 65 and older (Mean age 72.0, 47.4% male) residing in Canberra, Australia. The intervention group (n = 28) received a two-hour class-based road rules refresher course, and two one-hour driving lessons tailored to improve poor driving skills and habits identified in a baseline on-road assessment. The control group (n = 29) received the road rules refresher course only. Tests of cognitive performance, and on-road driving were conducted at baseline and at 12-weeks. Main outcome measure was the Driver safety rating (DSR) on the on-road driving test. The number of Critical Errors made during the on-road was also recorded. 55 drivers completed the trial (intervention group: 27, control group: 28). Both groups showed reduction in dangerous/hazardous driver errors that required instructor intervention. From baseline to follow-up there was a greater reduction in the number of critical errors made by the intervention group relative to the control group (IRR = 0.53, SE = 0.1, p = .008). The intervention group improved on the DSR more than the control group (intervention mean change = 1.07 SD = 2.00, control group mean change = 0.32 SD = 1.61). The intervention group had 64% remediation of unsafe driving, where drivers who achieved a score of 'fail' at baseline, 'passed' at follow-up. The control group had 25% remediation. Tailored driving lessons reduced the critical driving errors made by older adults. Longer term follow-up and larger trials are required. Copyright © 2018 Elsevier Ltd. All rights reserved.

  6. Classroom Management and Loss of Time at the Lesson Start: A Preliminary Study

    ERIC Educational Resources Information Center

    Saloviita, Timo

    2013-01-01

    Lesson starts are transitional events which may cause management problems for teachers. In this study 131 lesson starts of equally many teachers were observed in primary and secondary schools in Finland. The results indicated that, in general, the problems were minimal. However, for various reasons lesson starts were delayed by an average of about…

  7. Read Code Quality Assurance

    PubMed Central

    Schulz, Erich; Barrett, James W.; Price, Colin

    1998-01-01

    As controlled clinical vocabularies assume an increasing role in modern clinical information systems, so the issue of their quality demands greater attention. In order to meet the resulting stringent criteria for completeness and correctness, a quality assurance system comprising a database of more than 500 rules is being developed and applied to the Read Thesaurus. The authors discuss the requirement to apply quality assurance processes to their dynamic editing database in order to ensure the quality of exported products. Sources of errors include human, hardware, and software factors as well as new rules and transactions. The overall quality strategy includes prevention, detection, and correction of errors. The quality assurance process encompasses simple data specification, internal consistency, inspection procedures and, eventually, field testing. The quality assurance system is driven by a small number of tables and UNIX scripts, with “business rules” declared explicitly as Structured Query Language (SQL) statements. Concurrent authorship, client-server technology, and an initial failure to implement robust transaction control have all provided valuable lessons. The feedback loop for error management needs to be short. PMID:9670131

  8. Read Code quality assurance: from simple syntax to semantic stability.

    PubMed

    Schulz, E B; Barrett, J W; Price, C

    1998-01-01

    As controlled clinical vocabularies assume an increasing role in modern clinical information systems, so the issue of their quality demands greater attention. In order to meet the resulting stringent criteria for completeness and correctness, a quality assurance system comprising a database of more than 500 rules is being developed and applied to the Read Thesaurus. The authors discuss the requirement to apply quality assurance processes to their dynamic editing database in order to ensure the quality of exported products. Sources of errors include human, hardware, and software factors as well as new rules and transactions. The overall quality strategy includes prevention, detection, and correction of errors. The quality assurance process encompasses simple data specification, internal consistency, inspection procedures and, eventually, field testing. The quality assurance system is driven by a small number of tables and UNIX scripts, with "business rules" declared explicitly as Structured Query Language (SQL) statements. Concurrent authorship, client-server technology, and an initial failure to implement robust transaction control have all provided valuable lessons. The feedback loop for error management needs to be short.

  9. Instruct coders' manual

    NASA Technical Reports Server (NTRS)

    Friend, J.

    1971-01-01

    A manual designed both as an instructional manual for beginning coders and as a reference manual for the coding language INSTRUCT, is presented. The manual includes the major programs necessary to implement the teaching system and lists the limitation of current implementation. A detailed description is given of how to code a lesson, what buttons to push, and what utility programs to use. Suggestions for debugging coded lessons and the error messages that may be received during assembly or while running the lesson are given.

  10. Orwell's Instructive Errors

    ERIC Educational Resources Information Center

    Julian, Liam

    2009-01-01

    In this article, the author talks about George Orwell, his instructive errors, and the manner in which Orwell pierced worthless theory, faced facts and defended decency (with fluctuating success), and largely ignored the tradition of accumulated wisdom that has rendered him a timeless teacher--one whose inadvertent lessons, while infrequently…

  11. Lessons learned: wrong intraocular lens.

    PubMed

    Schein, Oliver D; Banta, James T; Chen, Teresa C; Pritzker, Scott; Schachat, Andrew P

    2012-10-01

    To report cases involving the placement of the wrong intraocular lens (IOL) at the time of cataract surgery where human error occurred. Retrospective small case series, convenience sample. Seven surgical cases. Institutional review of errors committed and subsequent improvements to clinical protocols. Lessons learned and changes in procedures adapted. The pathways to a wrong IOL are many but largely reflect some combination of poor surgical team communication, transcription error, lack of preoperative clarity in surgical planning or failure to match the patient, and IOL calculation sheet with 2 unique identifiers. Safety in surgery involving IOLs is enhanced both by strict procedures, such as an IOL-specific "time-out," and the fostering of a surgical team culture in which all members are encouraged to voice questions and concerns. Copyright © 2012 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.

  12. Mentoring Human Performance - 12480

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Geis, John A.; Haugen, Christian N.

    2012-07-01

    Although the positive effects of implementing a human performance approach to operations can be hard to quantify, many organizations and industry areas are finding tangible benefits to such a program. Recently, a unique mentoring program was established and implemented focusing on improving the performance of managers, supervisors, and work crews, using the principles of Human Performance Improvement (HPI). The goal of this mentoring was to affect behaviors and habits that reliably implement the principles of HPI to ensure continuous improvement in implementation of an Integrated Safety Management System (ISMS) within a Conduct of Operations framework. Mentors engaged with personnel inmore » a one-on-one, or one-on-many dialogue, which focused on what behaviors were observed, what factors underlie the behaviors, and what changes in behavior could prevent errors or events, and improve performance. A senior management sponsor was essential to gain broad management support. A clear charter and management plan describing the goals, objectives, methodology, and expected outcomes was established. Mentors were carefully selected with senior management endorsement. Mentors were assigned to projects and work teams based on the following three criteria: 1) knowledge of the work scope; 2) experience in similar project areas; and 3) perceived level of trust they would have with project management, supervision, and work teams. This program was restructured significantly when the American Reinvestment and Recovery Act (ARRA) and the associated funding came to an end. The program was restructured based on an understanding of the observations, attributed successes and identified shortfalls, and the consolidation of those lessons. Mentoring the application of proven methods for improving human performance was shown effective at increasing success in day-to-day activities and increasing confidence and level of skill of supervisors. While mentoring program effectiveness is difficult to measure, and return on investment is difficult to quantify, especially in complex and large organizations where the ability to directly correlate causal factors can be challenging, the evidence presented by Sydney Dekker, James Reason, and others who study the field of human factors does assert managing and reducing error is possible. Employment of key behaviors-HPI techniques and skills-can be shown to have a significant impact on error rates. Our mentoring program demonstrated reduced error rates and corresponding improvements in safety and production. Improved behaviors are the result, of providing a culture with consistent, clear expectations from leadership, and processes and methods applied consistently to error prevention. Mentoring, as envisioned and executed in this program, was effective in helping shift organizational culture and effectively improving safety and production. (authors)« less

  13. Steering without navigation equipment: the lamentable state of Australian health policy reform

    PubMed Central

    2009-01-01

    Background Commentary on health policy reform in Australia often commences with an unstated logical error: Australians' health is good, therefore the Australian Health System is good. This possibly explains the disconnect between the options discussed, the areas needing reform and the generally self-congratulatory tone of the discussion: a good system needs (relatively) minor improvement. Results This paper comments on some issues of particular concern to Australian health policy makers and some areas needing urgent reform. The two sets of issues do not overlap. It is suggested that there are two fundamental reasons for this. The first is the failure to develop governance structures which promote the identification and resolution of problems according to their importance. The second and related failure is the failure to equip the health services industry with satisfactory navigation equipment - independent research capacity, independent reporting and evaluation - on a scale commensurate with the needs of the country's largest industry. These two failures together deprive the health system - as a system - of the chief driver of progress in every successful industry in the 20th Century. Conclusion Concluding comment is made on the National Health and Hospitals Reform Commission (NHHRC). This continued the tradition of largely evidence free argument and decision making. It failed to identify and properly analyse major system failures, the reasons for them and the form of governance which would maximise the likelihood of future error leaning. The NHHRC itself failed to error learn from past policy failures, a key lesson from which is that a major - and possibly the major - obstacle to reform, is government itself. The Commission virtually ignored the issue of governance. The endorsement of a monopolised system, driven by benevolent managers will miss the major lesson of history which is illustrated by Australia's own failures. PMID:19948044

  14. Classroom Management in Pre-Service Teachers' Teaching Practice Demo Lessons: A Comparison to Actual Lessons by In-Service English Teachers

    ERIC Educational Resources Information Center

    Korkut, Perihan

    2017-01-01

    The pre-service teachers find the chance to practice their classroom management skills during their practicum as they present demo lessons under supervision of their university instructors and mentor teachers. It had been discovered in a previous study, however, that the interactional features during the classroom management episodes in…

  15. Biomedical Mathematics, Unit II: Propagation of Error, Vectors and Linear Programming. Instructor's Manual. Revised Version, 1975.

    ERIC Educational Resources Information Center

    Biomedical Interdisciplinary Curriculum Project, Berkeley, CA.

    This instructor's manual presents lesson plans for a unit of mathematics within the Biomedical Interdisciplinary Curriculum Project (BICP), a two-year interdisciplinary precollege curriculum aimed at preparing high school students for entry into college and vocational programs leading to a career in the health field. Lessons concentrate on…

  16. Circulating Laptops: Lessons Learned in an Academic Library

    ERIC Educational Resources Information Center

    Sharpe, Paul A.

    2009-01-01

    Laptops have become ubiquitous in academic libraries, as has the practice of circulating laptops for student use. Several studies have analyzed the how-to of loaning laptops, and a number of surveys have focused on how they are being used. However, little has been written of the practical lessons learned; the trial and error of those on the…

  17. Simulation: learning from mistakes while building communication and teamwork.

    PubMed

    Kuehster, Christina R; Hall, Carla D

    2010-01-01

    Medical errors are one of the leading causes of death annually in the United States. Many of these errors are related to poor communication and/or lack of teamwork. Using simulation as a teaching modality provides a dual role in helping to reduce these errors. Thorough integration of clinical practice with teamwork and communication in a safe environment increases the likelihood of reducing the error rates in medicine. By allowing practitioners to make potential errors in a safe environment, such as simulation, these valuable lessons improve retention and will rarely be repeated.

  18. Weapon System Management to Directorate of Logistics Management Systems Requirements (XRB) DCS/Plans and Programs Air Force Logistics Command Wright-Patterson AFB, Ohio 45433.

    DTIC Science & Technology

    1982-05-14

    Attachment 2 contains the reports and lessons learned which resulted from the Level II Weapon System Management activities. Attachment 3 contains the reports...and lessons learned which resulted from the Level III Weapon System Management activities. _____ r. Air Force Logistics Command Attn: Col. McConnell 2...May 14, 1982 Attachment 4 contains the plans and lessons learned which resulted from the RCC Evaluation activities. I am pleased to deliver these

  19. Lessons from aviation - the role of checklists in minimally invasive cardiac surgery.

    PubMed

    Hussain, S; Adams, C; Cleland, A; Jones, P M; Walsh, G; Kiaii, B

    2016-01-01

    We describe an adverse event during minimally invasive cardiac surgery that resulted in a multi-disciplinary review of intra-operative errors and the creation of a procedural checklist. This checklist aims to prevent errors of omission and communication failures that result in increased morbidity and mortality. We discuss the application of the aviation - led "threats and errors model" to medical practice and the role of checklists and other strategies aimed at reducing medical errors. © The Author(s) 2015.

  20. Trauma center maturity measured by an analysis of preventable and potentially preventable deaths: there is always something to be learned….

    PubMed

    Matsumoto, Shokei; Jung, Kyoungwon; Smith, Alan; Coimbra, Raul

    2018-06-23

    To establish the preventable and potentially preventable death rates in a mature trauma center and to identify the causes of death and highlight the lessons learned from these cases. We analyzed data from a Level-1 Trauma Center Registry, collected over a 15-year period. Data on demographics, timing of death, and potential errors were collected. Deaths were judged as preventable (PD), potentially preventable (PPD), or non-preventable (NPD), following a strict external peer-review process. During the 15-year period, there were 874 deaths, 15 (1.7%) and 6 (0.7%) of which were considered PPDs and PDs, respectively. Patients in the PD and PPD groups were not sicker and had less severe head injury than those in the NPD group. The time-death distribution differed according to preventability. We identified 21 errors in the PD and PPD groups, but only 61 (7.3%) errors in the NPD group (n = 853). Errors in judgement accounted for the majority and for 90.5% of the PD and PPD group errors. Although the numbers of PDs and PPDs were low, denoting maturity of our trauma center, there are important lessons to be learned about how errors in judgment led to deaths that could have been prevented.

  1. Applying lessons learned to enhance human performance and reduce human error for ISS operations

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Nelson, W.R.

    1999-01-01

    A major component of reliability, safety, and mission success for space missions is ensuring that the humans involved (flight crew, ground crew, mission control, etc.) perform their tasks and functions as required. This includes compliance with training and procedures during normal conditions, and successful compensation when malfunctions or unexpected conditions occur. A very significant issue that affects human performance in space flight is human error. Human errors can invalidate carefully designed equipment and procedures. If certain errors combine with equipment failures or design flaws, mission failure or loss of life can occur. The control of human error during operation ofmore » the International Space Station (ISS) will be critical to the overall success of the program. As experience from Mir operations has shown, human performance plays a vital role in the success or failure of long duration space missions. The Department of Energy{close_quote}s Idaho National Engineering and Environmental Laboratory (INEEL) is developing a systematic approach to enhance human performance and reduce human errors for ISS operations. This approach is based on the systematic identification and evaluation of lessons learned from past space missions such as Mir to enhance the design and operation of ISS. This paper will describe previous INEEL research on human error sponsored by NASA and how it can be applied to enhance human reliability for ISS. {copyright} {ital 1999 American Institute of Physics.}« less

  2. Applying lessons learned to enhance human performance and reduce human error for ISS operations

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Nelson, W.R.

    1998-09-01

    A major component of reliability, safety, and mission success for space missions is ensuring that the humans involved (flight crew, ground crew, mission control, etc.) perform their tasks and functions as required. This includes compliance with training and procedures during normal conditions, and successful compensation when malfunctions or unexpected conditions occur. A very significant issue that affects human performance in space flight is human error. Human errors can invalidate carefully designed equipment and procedures. If certain errors combine with equipment failures or design flaws, mission failure or loss of life can occur. The control of human error during operation ofmore » the International Space Station (ISS) will be critical to the overall success of the program. As experience from Mir operations has shown, human performance plays a vital role in the success or failure of long duration space missions. The Department of Energy`s Idaho National Engineering and Environmental Laboratory (INEEL) is developed a systematic approach to enhance human performance and reduce human errors for ISS operations. This approach is based on the systematic identification and evaluation of lessons learned from past space missions such as Mir to enhance the design and operation of ISS. This paper describes previous INEEL research on human error sponsored by NASA and how it can be applied to enhance human reliability for ISS.« less

  3. Management strategies to effect change in intensive care units: lessons from the world of business. Part I. Targeting quality improvement initiatives.

    PubMed

    Gershengorn, Hayley B; Kocher, Robert; Factor, Phillip

    2014-02-01

    The business community has developed strategies to ensure the quality of the goods or services they produce and to improve the management of multidisciplinary work teams. With modification, many of these techniques can be imported into intensive care units (ICUs) to improve clinical operations and patient safety. In Part I of a three-part ATS Seminar series, we argue for adopting business management strategies in ICUs and set forth strategies for targeting selected quality improvement initiatives. These tools are relevant to health care today as focus is placed on limiting low-value care and measuring, reporting, and improving quality. In the ICU, the complexity of illness and the need to standardize processes make these tools even more appealing. Herein, we highlight four techniques to help prioritize initiatives. First, the "80/20 rule" mandates focus on the few (20%) interventions likely to drive the majority (80%) of improvement. Second, benchmarking--a process of comparison with peer units or institutions--is essential to identifying areas of strength and weakness. Third, root cause analyses, in which structured retrospective reviews of negative events are performed, can be used to identify and fix systems errors. Finally, failure mode and effects analysis--a process aimed at prospectively identifying potential sources of error--allows for systems fixes to be instituted in advance to prevent negative outcomes. These techniques originated in fields other than health care, yet adoption has and can help ICU managers prioritize issues for quality improvement.

  4. 25+ Years of the Hubble Space Telescope and a Simple Error That Cost Millions

    ERIC Educational Resources Information Center

    Shakerin, Said

    2016-01-01

    A simple mistake in properly setting up a measuring device caused millions of dollars to be spent in correcting the initial optical failure of the Hubble Space Telescope (HST). This short article is intended as a lesson for a physics laboratory and discussion of errors in measurement.

  5. Application of Human Factors Methods to Design Healthcare Work Systems: Instance of the prevention of Adverse Drug Events.

    PubMed

    Marcilly, Romaric; Beuscart-Zephir, Marie-Catherine

    2015-01-01

    Human Factors (HF) methods are increasingly needed to support the design of new technologies in order to avoid that introducing those technologies into healthcare work systems induces use errors with potentially catastrophic consequences for the patients. This chapter illustrates the application of HF methods in developing two health technologies aiming at securing the hospital medication management process. Lessons learned from this project highlight the importance of (i) analyzing the work system in which the technology is intended to be implemented, (ii) involving end users in the design process and (iii) the intermediation role of HF between end users and scientific/technical experts.

  6. From Here to There: Lessons from an Integrative Patient Safety Project in Rural Health Care Settings

    DTIC Science & Technology

    2005-05-01

    errors and patient falls. The medication errors generally involved one of three issues: incorrect dose, time, or port. Although most of the health...statistics about trends; and the summary of events related to patient safety and medical errors.12 The interplay among factors These three domains...the medical staff. We explored these issues further when administering a staff-wide Patient Safety Survey. Responses mirrored the findings that

  7. Lessons Learned from a Decade of Sudden Oak Death in California: Evaluating Local Management

    NASA Astrophysics Data System (ADS)

    Alexander, Janice; Lee, Christopher A.

    2010-09-01

    Sudden Oak Death has been impacting California’s coastal forests for more than a decade. In that time, and in the absence of a centrally organized and coordinated set of mandatory management actions for this disease in California’s wildlands and open spaces, many local communities have initiated their own management programs. We present five case studies to explore how local-level management has attempted to control this disease. From these case studies, we glean three lessons: connections count, scale matters, and building capacity is crucial. These lessons may help management, research, and education planning for future pest and disease outbreaks.

  8. Lessons Learned from a Decade of Sudden Oak Death in California: Evaluating Local Management

    PubMed Central

    Alexander, Janice

    2010-01-01

    Sudden Oak Death has been impacting California’s coastal forests for more than a decade. In that time, and in the absence of a centrally organized and coordinated set of mandatory management actions for this disease in California’s wildlands and open spaces, many local communities have initiated their own management programs. We present five case studies to explore how local-level management has attempted to control this disease. From these case studies, we glean three lessons: connections count, scale matters, and building capacity is crucial. These lessons may help management, research, and education planning for future pest and disease outbreaks. PMID:20559634

  9. Orientation/Time Management Skill Training Lesson: Development and Evaluation

    DTIC Science & Technology

    1979-07-01

    instructional environment. This Orientation/ Time Management lesson provides students with appropriate role models for increasing acceptance of their...time savings can be obtained by a combination of this type of orientation and time management skill training with a computer-based progress targeting

  10. Prototyping with Application Generators: Lessons Learned from the Naval Aviation Logistics Command Management Information System Case

    DTIC Science & Technology

    1992-10-01

    Prototyping with Application Generators: Lessons Learned from the Naval Aviation Logistics Command Management Information System Case. This study... management information system to automate manual Naval aviation maintenance tasks-NALCOMIS. With the use of a fourth-generation programming language

  11. Space Flight Resource Management Training for International Space Station Flight Controllers

    NASA Technical Reports Server (NTRS)

    O'Keefe, William S.

    2011-01-01

    Training includes both SFRM-dedicated lessons and SFRM training embedded into technical lessons. Goal is to reduce certification times by 50% and integrated simulations by 75-90%. SFRM is practiced, evaluated and debriefed in part task trainers and full-task simulation lessons. SFRM model and training are constantly being evaluated against student/management feedback, best practices from industry/ military, and latest research.

  12. Revising the Depreciation and Investment Credit Lessons for Farm Management and Supervised Occupational Experience for Use in Missouri Programs of Vocational Agriculture. Final Report.

    ERIC Educational Resources Information Center

    Rohrbach, Norman; And Others

    This project developed four lessons that reflect the 1981 tax laws as they relate to the use of investment credit and depreciation in farm accounting systems. Project staff reviewed tax laws and related materials and identified four lessons in farm management and supervised occupational experience that needed revision. Materials were then…

  13. Adolescent health and social problems. A method for detection and early management. The Dartmouth Primary Care Cooperative Information Project (COOP).

    PubMed

    Wasson, J H; Kairys, S W; Nelson, E C; Kalishman, N; Baribeau, P; Wasson, E

    1995-01-01

    To develop and test a method for identification and early management of the health and social problems of adolescents, many of which go undetected and untreated. Picture-and-word charts for the measurement of health and social problems formed the core of a brief, self-teaching lesson. Other sections of the lesson were designed to help teenagers interpret, invent solutions for, and communicate concerns about these problems. We examined the impact of the lesson on teenagers' understanding of themselves, their feelings, and their actions. Two hundred ninety-one adolescents served as subjects for this research. Less than 5% of the respondents found the chart-based lesson difficult or bothersome in the way it probed personal topics. Ninety percent reported that the lesson would have some positive impact on their actions or feelings. Three to six weeks after completing the lesson, their opinion of its impact remained high, and 36% of the students reported that they had shown it to others outside the school. A chart-based lesson is well accepted by adolescents and can be used to overcome obstacles for the detection and early management of adolescents' health and social problems.

  14. Stop! Look & Lesson: A Guide to Identifying and Correcting Common Mathematical Errors Strategies.

    ERIC Educational Resources Information Center

    Palmer, Don; And Others

    This book provides a comprehensive collection of 66 teaching strategies and ideas to help overcome problems with number, each linked to a specific kind of error described in the related manual. Most of these strategies are classroom-ready and easily implemented. Some are notes for the teacher to read and then plan activities accordingly, and many…

  15. Apollo 1 Lessons Learned Show

    NASA Image and Video Library

    2017-01-27

    Mike Ciannilli, the Apollo, Challenger, Columbia Lessons Learned program manager, at left, presents a certificate to Ernie Reyes, retired, former Apollo 1 senior operations manager, during the Apollo 1 Lessons Learned presentation in the Training Auditorium at NASA's Kennedy Space Center in Florida. The theme of the program was "To there and Back Again." The event helped pay tribute to the Apollo 1 crew, Gus Grissom, Ed White II, and Roger Chaffee.

  16. Lessons Learned Study Final Report for the Exploration Systems Mission Directorate

    NASA Technical Reports Server (NTRS)

    Van Laak, Jim; Brumfield, M. Larry; Moore, Arlene A.; Anderson, Brooke; Dempsey, Jim; Gifford, Bob; Holloway, Chip; Johnson, Keith

    2004-01-01

    This report is the final product of a 90-day study performed for the Exploration Systems Mission Directorate. The study was to assemble lessons NASA has learned from previous programs that could help the Exploration Systems Mission Directorate pursue the Exploration vision. It focuses on those lessons that should have the greatest significance to the Directorate during the formulation of program and mission plans. The study team reviewed a large number of lessons learned reports and data bases, including the Columbia Accident Investigation Board and Rogers Commission reports on the Shuttle accidents, accident reports from robotic space flight systems, and a number of management reviews by the Defense Sciences Board, Government Accountability Office, and others. The consistency of the lessons, findings, and recommendations validate the adequacy of the data set. In addition to reviewing existing databases, a series of workshops was held at each of the NASA centers and headquarters that included senior managers from the current workforce as well as retirees. The full text of the workshop reports is included in Appendix A. A lessons learned website was opened up to permit current and retired NASA personnel and on-site contractors to input additional lessons as they arise. These new lessons, when of appropriate quality and relevance, will be brought to the attention of managers. The report consists of four parts: Part 1 provides a small set of lessons, called the Executive Lessons Learned, that represent critical lessons that the Exploration Systems Mission Directorate should act on immediately. This set of Executive Lessons and their supporting rationale have been reviewed at length and fully endorsed by a team of distinguished NASA alumni; Part 2 contains a larger set of lessons, called the Selected Lessons Learned, which have been chosen from the lessons database and center workshop reports on the basis of their specific significance and relevance to the near-term work of the Exploration Directorate. These lessons frequently support the Executive lessons but are more general in nature; Part 3 consists of the reports of the center workshops that were conducted as part of this activity. These reports are included in their entirety (approximately 200 pages) in Appendix G and have significance for specific managers; Part 4 consists of the remainder of the lessons that have been selected by this effort and assembled into a database for the use of the Explorations Directorate. The database is archived and hosted in the Lessons Learned Knowledge Network, which provides a flexible search capability using a wide variety of search terms. Finally, a spreadsheet lists databases searched and a bibliography identifies reports that have been reviewed as sources of lessons for this task. NASA has been presented with many learning opportunities. We have conducted numerous programs, some extremely successful and others total failures. Most have been documented with a formal lessons learned activity, but we have not always incorporated these learning opportunities into our normal modes of business. For example, the Robbins Report of 2001 clearly indicates that many project failures of the past two decades were the result of violating well documented best practices, often in direct violation of management instructions and directives. An overarching lesson emerges: that disciplined execution in accordance with proven best practices is the greatest single contributor to a successful program. The Lessons Learned task team offers a sincere hope that the lessons presented herein will be helpful to the Exploration Systems Directorate in charting and executing their course. The success of the Directorate and of NASA in general depends on our collective ability to move forward without having to relearn the lessons of those who have gone before.

  17. Apollo 1 Lessons Learned Show

    NASA Image and Video Library

    2017-01-27

    Mike Ciannilli, the Apollo, Challenger, Columbia Lessons Learned Program manager, far right, is pictured with panelists from the Apollo 1 Lessons Learned event in the Training Auditorium at NASA's Kennedy Space Center in Florida. In the center, are Ernie Reyes, retired, former Apollo 1 senior operations manager; and John Tribe, retired, former Apollo 1 Reaction and Control System lead engineer. At far left is Zulie Cipo, the Apollo, Challenger, Columbia Lessons Learned Program event support team lead. The theme of the program was "To there and Back Again." The event helped pay tribute to the Apollo 1 crew, Gus Grissom, Ed White II, and Roger Chaffee.

  18. Development of a Template Lesson Plan Based on 5e Model Enhanced with Computer Supported Applications and Conceptual Change Texts

    ERIC Educational Resources Information Center

    Seker, Burcu Sezginsoy; Erdem, Aliye

    2017-01-01

    Students learning a defined subject only perform by learning of thinking based on the concepts forming that subjects. Otherwise, students may move away from the scientific meaning of concepts and may fall into conceptual errors. Students' conceptual errors affect their following learning and cause them resist change. It is possible to prevent this…

  19. Reflecting on 25 Years of Teaching, Researching, and Textbook Writing for Introduction to Management: An Essay with Some Lessons Learned

    ERIC Educational Resources Information Center

    Dyck, Bruno

    2017-01-01

    This essay describes innovations made and lessons learned while teaching introduction to management courses during a 25-year career. The essay describes how teaching two approaches to management increases students' critical and ethical thinking, and reverses the tendency for business students to become increasingly materialistic and…

  20. Noncombatant Evacuation Operations: Department of State’s Lessons Learned Program

    DTIC Science & Technology

    2016-06-10

    student author and do not necessarily represent the views of the U.S. Army Command and General Staff College or any other U.S. governmental agency...68 viii ACRONYMS AAR After Action Review CALL Center for Army Lessons Learned CMS Crisis Management Support CMU Crisis Management ...Knowledge Management Chart .......................................................................25 Figure 5. Organization Chart

  1. Tangential Floor in a Classroom Setting

    ERIC Educational Resources Information Center

    Marti, Leyla

    2012-01-01

    This article examines floor management in two classroom sessions: a task-oriented computer lesson and a literature lesson. Recordings made in the computer lesson show the organization of floor when a task is given to students. Temporary or "incipient" side floors (Jones and Thornborrow, 2004) emerge beside the main floor. In the literature lesson,…

  2. Can We Defend the Defense Supply Chain Lessons Learned from Industry Leaders in Supply Chain Management

    DTIC Science & Technology

    2018-03-01

    Directorate for Information Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302, and to the Office of Management and...chain, including products, services, information , finances, demand, relationships, and risks. In a more complete definition, supply chain management ...CHAIN? LESSONS LEARNED FROM INDUSTRY LEADERS IN SUPPLY CHAIN MANAGEMENT by Ronald H. Menz March 2018 Thesis Co-Advisors: Rodrigo Nieto-Gomez

  3. Commercial Orbital Transportation Services (COTS) Program Lessons Learned

    NASA Technical Reports Server (NTRS)

    Lindenmoyer, Alan; Horkachuck, Mike; Shotwell, Gwynne; Manners, Bruce; Culbertson, Frank

    2015-01-01

    This report has been developed by the National Aeronautics and Space Administration (NASA) Human Exploration and Operations Mission Directorate (HEOMD) Risk Management team in close coordination with the COTS Program. This document provides a point-in-time, cumulative, summary of actionable key lessons learned derived from the design project. Lessons learned invariably address challenges and risks and the way in which these areas have been addressed. Accordingly the risk management thread is woven throughout the document.

  4. Driving improvement in patient care: lessons from Toyota.

    PubMed

    Thompson, Debra N; Wolf, Gail A; Spear, Steven J

    2003-11-01

    Nurses today are attempting to do more with less while grappling with faulty error-prone systems that do not focus on patients at the point of care. This struggle occurs against a backdrop of rising national concern over the incidence of medical errors in healthcare. In an effort to create greater value with scarce resources and fix broken systems that compromise quality care, UPMC Health System is beginning to master and implement the Toyota Production System (TPS)--a method of managing people engaged in work that emphasizes frequent rapid problem solving and work redesign that has become the global archetype for productivity and performance. The authors discuss the rationale for applying TPS to healthcare and implementation of the system through the development of "learning unit" model lines and initial outcomes, such as dramatic reductions in the number of missing medications and thousands of hours and dollars saved as a result of TPS-driven changes. Tracking data further suggest that TPS, with sufficient staff preparation and involvement, has the potential for continuous, lasting, and accelerated improvement in patient care.

  5. Family Medicine in Ethiopia: Lessons from a Global Collaboration.

    PubMed

    Evensen, Ann; Wondimagegn, Dawit; Zemenfes Ashebir, Daniel; Rouleau, Katherine; Haq, Cynthia; Ghavam-Rassoul, Abbas; Janakiram, Praseedha; Kvach, Elizabeth; Busse, Heidi; Conniff, James; Cornelson, Brian

    2017-01-01

    Building the capacity of local health systems to provide high-quality, self-sustaining medical education and health care is the central purpose for many global health partnerships (GHPs). Since 2001, our global partner consortium collaborated to establish Family Medicine in Ethiopia; the first Ethiopian family physicians graduated in February 2016. The authors, representing the primary Ethiopian, Canadian, and American partners in the GHP, identified obstacles, accomplishments, opportunities, errors, and observations from the years preceding residency launch and the first 3 years of the residency. Common themes were identified through personal reflection and presented as lessons to guide future GHPs. LESSON 1: Promote Family Medicine as a distinct specialty. LESSON 2: Avoid gaps, conflict, and redundancy in partner priorities and activities. LESSON 3: Building relationships takes time and shared experiences. LESSON 4: Communicate frequently to create opportunities for success. LESSON 5: Engage local leaders to build sustainable, long-lasting programs from the beginning of the partnership. GHPs can benefit individual participants, their organizations, and their communities served. Engaging with numerous partners may also result in challenges-conflicting expectations, misinterpretations, and duplication or gaps in efforts. The lessons discussed in this article may be used to inform GHP planning and interactions to maximize benefits and minimize mishaps. © Copyright 2017 by the American Board of Family Medicine.

  6. Rethinking Recycling: Why Teach about Garbage?

    ERIC Educational Resources Information Center

    Clearing, 1993

    1993-01-01

    Ties environmental education, via garbage disposal issues, to Oregon's educational reform agenda. Discusses teaching the basics through "garbage" lessons. Includes how to (1) take an interdisciplinary approach; (2) introduce waste management concepts in other lessons; (3) use waste management examples to apply existing concepts; and (4)…

  7. 77 FR 14446 - Changes to the Generic Aging Lessons Learned (GALL) Report Revision 2 AMP XI.M41, “Buried and...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-03-09

    ... NUCLEAR REGULATORY COMMISSION [NRC-2012-0055] Changes to the Generic Aging Lessons Learned (GALL... Aging Lessons Learned (GALL) Report,'' and the NRC staff's aging management review procedure and... into ADAMS. II. Background The NRC issues LR-ISGs to communicate insights and lessons learned and to...

  8. Integrating Satellite and Surface Sensor Networks for Irrigation Management Applications in California

    NASA Astrophysics Data System (ADS)

    Melton, F. S.; Johnson, L.; Post, K. M.; Guzman, A.; Zaragoza, I.; Spellenberg, R.; Rosevelt, C.; Michaelis, A.; Nemani, R. R.; Cahn, M.; Frame, K.; Temesgen, B.; Eching, S.

    2016-12-01

    Satellite mapping of evapotranspiration (ET) from irrigated agricultural lands can provide agricultural producers and water managers with information that can be used to optimize agricultural water use, especially in regions with limited water supplies. The timely delivery of information on agricultural crop water requirements has the potential to make irrigation scheduling more practical, convenient, and accurate. We present a system for irrigation scheduling and management support in California and describe lessons learned from the development and implementation of the system. The Satellite Irrigation Management Support (SIMS) framework integrates satellite data with information from agricultural weather networks to map crop canopy development, basal crop coefficients (Kcb), and basal crop evapotranspiration (ETcb) at the scale of individual fields. Information is distributed to agricultural producers and water managers via a web-based irrigation management decision support system and web data services. SIMS also provides an application programming interface (API) that facilitates integration with other irrigation decision support tools, estimation of total crop evapotranspiration (ETc) and calculation of on-farm water use efficiency metrics. Accuracy assessments conducted in commercial fields for more than a dozen crop types to date have shown that SIMS seasonal ETcb estimates are within 10% mean absolute error (MAE) for well-watered crops and within 15% across all crop types studied, and closely track daily ETc and running totals of ETc measured in each field. Use of a soil water balance model to correct for soil evaporation and crop water stress reduces this error to less than 8% MAE across all crop types studied to date relative to field measurements of ETc. Results from irrigation trials conducted by the project for four vegetable crops have also demonstrated the potential for use of ET-based irrigation management strategies to reduce total applied water by 20-40% relative to grower standard practices while maintaining crop yields and quality.

  9. Issues in NASA program and project management

    NASA Technical Reports Server (NTRS)

    Hoban, Francis T. (Editor)

    1988-01-01

    This collection of papers and resources on aerospace management issues is inspired by a desire to benefit from the lessons learned from past projects and programs. Inherent in the NASA culture is a respect for divergent viewpoints and innovative ways of doing things. This publication presents a wide variety of views and opinions. Good management is enhanced when program and project managers examine the methods of veteran managers, considering the lessons they have learned and reflected on their own guiding principles.

  10. Advanced software development workstation: Effectiveness of constraint-checking. [spaceflight simulation and planning

    NASA Technical Reports Server (NTRS)

    Izygon, Michel

    1992-01-01

    This report summarizes the findings and lessons learned from the development of an intelligent user interface for a space flight planning simulation program, in the specific area related to constraint-checking. The different functionalities of the Graphical User Interface part and of the rule-based part of the system have been identified. Their respective domain of applicability for error prevention and error checking have been specified.

  11. Systems Engineering Lessons Learned from Solar Array Structures and Mechanisms Deployment

    NASA Technical Reports Server (NTRS)

    Vipavetz, Kevin; Kraft, Thomas

    2013-01-01

    This report has been developed by the National Aeronautics and Space Administration (NASA) Human Exploration and Operations Mission Directorate (HEOMD) Risk Management team in close coordination with the Engineering Directorate at LaRC. This document provides a point-in-time, cumulative, summary of actionable key lessons learned derived from the design project. Lessons learned invariably address challenges and risks and the way in which these areas have been addressed. Accordingly the risk management thread is woven throughout the document.

  12. San Antonio's Medical Center Corridor: Lessons Learned From The Metropolitan Model Deployment Initiative: Reducing Delay Through Integrated Freeway & Arterial Management

    DOT National Transportation Integrated Search

    2000-10-01

    This report demonstrates the benefits and potential pitfalls of deploying and operating an integrated freeway and arterial management system. In particular, it discusses the lessons learned about the Medical Center Corridor (MCC) Project deployed in ...

  13. Managing Physical Education Lessons: An Interactional Approach

    ERIC Educational Resources Information Center

    Barker, Dean; Annerstedt, Claes

    2016-01-01

    Physical education (PE) lessons involve complex and dynamic interactive sequences between students, equipment and teacher. The potential for unexpected and/or unintended events is relatively large, a point reflected in an increasing amount of scholarship dealing with classroom management (CM). This scholarship further suggests that unexpected and…

  14. Transitioning to a new nursing home: one organization's experience.

    PubMed

    O'Brien, Kelli; Welsh, Darlene; Lundrigan, Elaine; Doyle, Anne

    2013-01-01

    Restructuring of long-term care in Western Health, a regional health authority within Newfoundland and Labrador, created a unique opportunity to study the widespread impacts of the transition. Staff and long-term-care residents were relocated from a variety of settings to a newly constructed facility. A plan was developed to assess the impact of relocation on staff, residents, and families. Indicators included fall rates, medication errors, complaints, media database, sick leave, overtime, injuries, and staff and family satisfaction. This article reports on the findings and lessons learned from an organizational perspective with such a large-scale transition. Some of the key findings included the necessity of premove and postmove strategies to minimize negative impacts, ongoing communication and involvement in decision making during transitions, tracking of key indicators, recognition from management regarding increased workload and stress experienced by staff, engagement of residents and families throughout the transition, and assessing the timing of large-scale relocations. These findings would be of interest to health care managers and leadership team in organizations planning large-scale changes.

  15. Onshore and Offshore Outsourcing with Agility: Lessons Learned

    NASA Astrophysics Data System (ADS)

    Kussmaul, Clifton

    This chapter reflects on case study based an agile distributed project that ran for approximately three years (from spring 2003 to spring 2006). The project involved (a) a customer organization with key personnel distributed across the US, developing an application with rapidly changing requirements; (b) onshore consultants with expertise in project management, development processes, offshoring, and relevant technologies; and (c) an external offsite development team in a CMM-5 organization in southern India. This chapter is based on surveys and discussions with multiple participants. The several years since the project was completed allow greater perspective on both the strengths and weaknesses, since the participants can reflect on the entire life of the project, and compare it to subsequent experiences. Our findings emphasize the potential for agile project management in distributed software development, and the importance of people and interactions, taking many small steps to find and correct errors, and matching the structures of the project and product to support implementation of agility.

  16. Formal Validation of Fault Management Design Solutions

    NASA Technical Reports Server (NTRS)

    Gibson, Corrina; Karban, Robert; Andolfato, Luigi; Day, John

    2013-01-01

    The work presented in this paper describes an approach used to develop SysML modeling patterns to express the behavior of fault protection, test the model's logic by performing fault injection simulations, and verify the fault protection system's logical design via model checking. A representative example, using a subset of the fault protection design for the Soil Moisture Active-Passive (SMAP) system, was modeled with SysML State Machines and JavaScript as Action Language. The SysML model captures interactions between relevant system components and system behavior abstractions (mode managers, error monitors, fault protection engine, and devices/switches). Development of a method to implement verifiable and lightweight executable fault protection models enables future missions to have access to larger fault test domains and verifiable design patterns. A tool-chain to transform the SysML model to jpf-Statechart compliant Java code and then verify the generated code via model checking was established. Conclusions and lessons learned from this work are also described, as well as potential avenues for further research and development.

  17. Anchoring interprofessional education in undergraduate curricula: The Heidelberg story.

    PubMed

    Berger, Sarah; Goetz, Katja; Leowardi-Bauer, Christina; Schultz, Jobst-Hendrik; Szecsenyi, Joachim; Mahler, Cornelia

    2017-03-01

    The ability of health professionals to collaborate effectively has significant potential impact on patient safety and quality-care outcomes, especially given the increasingly complex and dynamic clinical practice environments of today. Educators of the health professions are faced with an immediate challenge to adapt curricula and traditional teaching methods to ensure graduates are equipped with the necessary interprofessional competencies and (inter)professional values for their future practice. The World Health Organization's "Framework for action in interprofessional education (IPE) and collaborative practice" promotes IPE as a key strategy to enhance patient outcomes by preparing a "collaborative practice-ready health workforce." Logistical and attitudinal barriers can hinder integration of IPE into curricula. Lessons learned through the implementation of a planned change to establish four interprofessional seminars (team communication, medical error communication, healthcare English, and small business management) at Heidelberg University Medical Faculty, Germany, are described. A key factor in successfully anchoring IPE seminars in the undergraduate curricula was the structured approach drawing on change management concepts.

  18. MISR: protection from ourselves

    NASA Technical Reports Server (NTRS)

    Nolan, T.; Varanasi, P.

    2004-01-01

    Outlines lessons learned by the Instrument Operations Team of NASA/JPL Terra's Multi-angle Imaging SpectroRadiometer mission. It narrates a story of MISR: Protection from Ourselves! and describes, in detail, how the MISR instrument survived operator errors.

  19. Host Control of Fungal Infections: Lessons from Basic Studies and Human Cohorts.

    PubMed

    Lionakis, Michail S; Levitz, Stuart M

    2018-04-26

    In the last few decades, the AIDS pandemic and the significant advances in the medical management of individuals with neoplastic and inflammatory conditions have resulted in a dramatic increase in the population of immunosuppressed patients with opportunistic, life-threatening fungal infections. The parallel development of clinically relevant mouse models of fungal disease and the discovery and characterization of several inborn errors of immune-related genes that underlie inherited human susceptibility to opportunistic mycoses have significantly expanded our understanding of the innate and adaptive immune mechanisms that protect against ubiquitous fungal exposures. This review synthesizes immunological knowledge derived from basic mouse studies and from human cohorts and provides an overview of mammalian antifungal host defenses that show promise for informing therapeutic and vaccination strategies for vulnerable patients.

  20. Soybean Production Lesson Plan.

    ERIC Educational Resources Information Center

    Carlson, Keith R.

    These lesson plans for teaching soybean production in a secondary or postsecondary vocational agriculture class are organized in nine units and cover the following topics: raising soybeans, optimum tillage, fertilizer and lime, seed selection, pest management, planting, troubleshooting, double cropping, and harvesting. Each lesson plan contains…

  1. Integrating External Software into SMART Board™ Calculus Lessons

    ERIC Educational Resources Information Center

    Wolmer, Allen; Khazanov, Leonid

    2011-01-01

    Interactive Whiteboards (IWBs) are becoming commonplace throughout primary, secondary, and postsecondary classrooms. However, the focus of the associated lesson creation & management software tools delivered with IWBs has been the primary grades, while secondary and postsecondary mathematics lessons have requirements beyond what is delivered…

  2. Lesson Learned from Leading an Anger Management Group Using the "Seeing Red" Curriculum within an Elementary School

    ERIC Educational Resources Information Center

    Sportsman, Emily L.; Carlson, John S.; Guthrie, Kelly M.

    2010-01-01

    Four fourth-grade boys participated in an anger management group using "Seeing Red: An Anger Management and Peacemaking Curriculum for Kids" facilitated by a school psychology intern and her supervisor (J. Simmonds, 2003). The group met for 30 min weekly for a total of 14 sessions. Lessons consisted of practicing skills and strategies related to…

  3. Evaluation of Natural Resource Education Materials: Implications for Resource Management.

    ERIC Educational Resources Information Center

    Pomerantz, Gerri A.

    1991-01-01

    An analysis of elementary school natural resource lessons (n=700) that focus on ecological principles, on resource management issues, and on analytical skill development affecting students' environmental behavior is presented. The fundamental conclusion is that very few of the lesson materials help to develop critical thinking skills and behaviors…

  4. Orientation/Time Management Skill Training Lesson: Development and Evaluation. Final Report.

    ERIC Educational Resources Information Center

    Dobrovolny, Jacqueline L.; And Others

    A lesson was developed containing materials designed to assist students in their adaptation to the novelties of a computer assisted or managed instructional environment, providing students with appropriate role models for increasing acceptance of their increased responsibility for learning and introducing a progress tracking approach to assist…

  5. Lawson's Shoehorn, or Should the Philosophy of Science Be Rated 'X'?

    ERIC Educational Resources Information Center

    Allchin, Douglas

    2003-01-01

    Addresses Lawson's (2002) interpretations of Galileo's discovery of the moons of Jupiter and other cases that exhibit historical errors. Suggests that such cases can distort history and lessons about the nature of science. (SOE)

  6. Intravenous medication safety and smart infusion systems: lessons learned and future opportunities.

    PubMed

    Keohane, Carol A; Hayes, Judy; Saniuk, Catherine; Rothschild, Jeffrey M; Bates, David W

    2005-01-01

    The Institute of Medicine report To Err Is Human: Building a Safe Health System greatly increased national awareness of the need to improve patient safety in general and medication safety in particular. Infusion-related errors are associated with the greatest risk of harm, and "smart" (computerized) infusion systems are currently available that can avert high-risk errors and provide previously unavailable data for continuous quality improvement (CQI) efforts. As healthcare organizations consider how to invest scarce dollars, infusion nurses have a key role to play in assessing need, evaluating technology, and selecting and implementing specific products. This article reviews the need to improve intravenous medication safety. It describes smart infusion systems and the results they have achieved. Finally, it details the lessons learned and the opportunities identified through the use of smart infusion technology at Brigham and Women's Hospital in Boston, Massachusetts.

  7. Tips from the Classroom: Introducing the Friendly and Useful Computer; Using Annotations to Identify Composition Errors; Building a Scaffold with Video Clips; Movie Karaoke; Gotcha.

    ERIC Educational Resources Information Center

    Dudley, Albert P.; And Others

    1997-01-01

    Presents various tips that are useful in the classroom for teaching second languages. These tips focus on teaching basic computer operations; using annotations to foster error corrections in language; using video clips as a part of a U.S. history or culture-based English-as-a-Second-Language lesson; using karaoke to speak with less inhibition; and…

  8. A web-based incident reporting system and multidisciplinary collaborative projects for patient safety in a Japanese hospital

    PubMed Central

    Nakajima, K; Kurata, Y; Takeda, H

    2005-01-01

    

Problem: When patient safety programs were mandated for Japanese health care institutions, a safety culture, a tool for collecting incident reports, an organizational arrangement for multidisciplinary collaboration, and interventional methods for improvement had to be established. Design: Observational study of effects of new patient safety programs. Setting: Osaka University Hospital, a large government-run teaching hospital. Strategy for change: A voluntary and anonymous web-based incident reporting system was introduced. For the new organizational structure a clinical risk management committee, a department of clinical quality management, and area clinical risk managers were established with their respective roles clearly defined to advance the plan-do-study-act cycle and to integrate efforts. For preventive action, alert procedures, staff education, ward rounds by peers, a system oriented approach for reducing errors, and various feedback channels were introduced. Effects of change: Continuous incident reporting by all hospital staff has been observed since the introduction of the new system. Several error inducing situations have been improved: wrong choice of drug in computer prescribing, maladministration of drugs due to a look-alike appearance or confusion about the manipulation of a medical device, and poor after hours service of the blood transfusion unit. Staff participation in educational seminars has been dramatically improved. Ward rounds have detected problematic procedures which needed to be dealt with. Lessons learnt: Patient safety programs based on a web-based incident reporting system, responsible persons, staff education, and a variety of feedback procedures can help promote a safety culture, multidisciplinary collaboration, and strong managerial leadership resulting in system oriented improvement. PMID:15805458

  9. Case study and lessons learned for the Great Lakes ITS Program, Airport ITS Integration and the Road Infrastructure Management System projects, final report, Wayne County, Michigan

    DOT National Transportation Integrated Search

    2007-03-02

    This report presents the case study and lessons learned for the national evaluation of the Great Lakes Intelligent Transportation Systems (GLITS) Airport ITS Integration and Road Infrastructure Management System (RIMS) projects. The Airport ITS Integ...

  10. 78 FR 33120 - Final Interim Staff Guidance LR-ISG-2011-04; Updated Aging Management Criteria for Reactor Vessel...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-06-03

    ..., ``Generic Aging Lessons Learned Report'' (GALL Report), for the aging management of Pressurized Water... communicate insights and lessons learned and to address emergent issues not covered in license renewal... ensure that PWR license renewal applicants will adequately address age-related degradation and aging...

  11. Farm Business Management Analysis: Analyzing the Farm Business. Unit II. Volume 13, Number 7.

    ERIC Educational Resources Information Center

    Denker, Robert; And Others

    Intended for use by Missouri vocational agricultural instructors in Farm Business Management Analysis programs for young and adult farmers, this curriculum guide contains 10 lessons in analyzing records. Each lesson is a self-contained instructional package and includes materials for monthly classroom sessions and monthly on-the-farm instructional…

  12. Closing the Loop: Exploring Integrated Waste Management and Resource Conservation, Kindergarten through Grade Six. 2000 Edition.

    ERIC Educational Resources Information Center

    Clymire, Olga

    This document is designed to teach concepts of source reduction, recycling, composting, and integrated waste management to kindergarten through grade six students. The lessons correlate to grade level and include sections on the lesson's concepts, purpose, overview, correlations to California's content standards and frameworks, scientific thinking…

  13. Military Curricula for Vocational & Technical Education. Introduction to Club Management, 9-8.

    ERIC Educational Resources Information Center

    Army Quartermaster School, Ft. Lee, VA.

    These lesson assignments, text materials, self-grading lesson exercises, and examination for a secondary-postsecondary subcourse in club management are one of a number of military-developed curriculum packages selected for adaptation to vocational instruction and curriculum development in a civilian setting. This introduction to the subcourse is…

  14. Genetics Home Reference: Imerslund-Gräsbeck syndrome

    MedlinePlus

    ... 1172-7-56. Citation on PubMed or Free article on PubMed Central Watkins D, Rosenblatt DS. Lessons in biology from patients with inborn errors of vitamin B12 metabolism. Biochimie. 2013 May;95(5):1019-22. doi: ...

  15. Solar Decathlon 2017: Final Report and Lessons Learned

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Incorporated, Energetics

    This final report introduces the Solar Decathlon 2017 Program Administrator, Core Advisory Committee, event sponsors and donors, and regional stakeholders that were integral to the success of Solar Decathlon 2017. The substantial balance of this report presents evaluative metrics and lessons learned about the primary aspects of administering Solar Decathlon 2017, including Project Management, Competition and Site Management, Stakeholder Engagement, Communications, Sponsor Management, Education Programming, and Volunteer Coordination. Several appendices compliment the discussion.

  16. Defense Acquisition University (DAU) Program Managers Tool Kit

    DTIC Science & Technology

    2008-03-01

    SUBTITLE Program Managers Tool Kit 5a. CONTRACT NUMBER 5b. GRANT NUMBER 5c. PROGRAM ELEMENT NUMBER 6. AUTHOR(S) 5d. PROJECT NUMBER 5e . TASK...strve for optmal solutons, seek better ways to manage, and provde lessons -learned to those who follow; • be candd about program status, ncludng...practces, lessons learned, and rsks to avod; • valdated practces wth consstent, verfiable nformaton; • an actve knowledge base to help wth

  17. Farm Business Management Analysis: Adjusting the Farm Business to Increase Profit. Unit III. Volume 15, Number 3. Instructor's Guide.

    ERIC Educational Resources Information Center

    Denker, Robert; And Others

    Designed primarily for Missouri vocational agricultural instructors participating in the Farm Business Management Analysis Program, this instructor's guide, consisting of 10 lessons, deals with adjusting a farm business to increase profits. The following topics are covered in the individual lessons: law and the farm family, planning income tax…

  18. Lessons Learned from Migrating to an Online Electronic Business Management Course

    ERIC Educational Resources Information Center

    Walstrom, Kent A.

    2014-01-01

    This article describes the lessons learned while migrating an Electronic Business Management course from traditional face-to-face delivery to online delivery across a six and a half year time frame. The course under review teaches students how to develop and construct a working information-based online business using free versions of online…

  19. Pocketwise: Personal Finance Economics K-2. Teacher Resource Manual. EconomicsAmerica.

    ERIC Educational Resources Information Center

    Carter, Carmen; Heiman, Jan; Mitchell, Julie; Morgan, Jack

    This book is designed to help students in grades K-2 make better decisions as spenders, savers, borrowers, and managers of money. The learning experiences focus on personal finance and money management. The 14 lessons are divided into 4 units focusing on money, spending, saving, and borrowing and credit. Lesson titles include: (1) "A Very…

  20. Farm Business Management Analysis. Unit II: Analyzing the Farm Business. Revised. Volume 25, Number 4.

    ERIC Educational Resources Information Center

    Riley, Jim

    The lessons in this unit are designed primarily for Missouri vocational agriculture instructors participating in the Farm Business Management Analysis program. Each of the 10 lessons in the unit is a self-contained instructional package and includes material for monthly classroom sessions for young and adult farmers and for individualized…

  1. Farm Business Management Analysis. Unit I: Establishing a Farm Accounting System. Revised. Volume 25, Number 3.

    ERIC Educational Resources Information Center

    Riley, Jim

    The lessons in this unit are designed primarily for Missouri vocational agriculture instructors participating in the Farm Business Management Analysis program. Each of the 10 lessons in the unit is a self-contained instructional package and includes material for monthly classroom sessions for young and adult farmers and for individualized…

  2. Safety and Mission Assurance Knowledge Management Retention: Managing Knowledge for Successful Mission Operations

    NASA Technical Reports Server (NTRS)

    Johnson, Teresa A.

    2006-01-01

    Knowledge Management is a proactive pursuit for the future success of any large organization faced with the imminent possibility that their senior managers/engineers with gained experiences and lessons learned plan to retire in the near term. Safety and Mission Assurance (S&MA) is proactively pursuing unique mechanism to ensure knowledge learned is retained and lessons learned captured and documented. Knowledge Capture Event/Activities/Management helps to provide a gateway between future retirees and our next generation of managers/engineers. S&MA hosted two Knowledge Capture Events during 2005 featuring three of its retiring fellows (Axel Larsen, Dave Whittle and Gary Johnson). The first Knowledge Capture Event February 24, 2005 focused on two Safety and Mission Assurance Safety Panels (Space Shuttle System Safety Review Panel (SSRP); Payload Safety Review Panel (PSRP) and the latter event December 15, 2005 featured lessons learned during Apollo, Skylab, and Space Shuttle which could be applicable in the newly created Crew Exploration Vehicle (CEV)/Constellation development program. Gemini, Apollo, Skylab and the Space Shuttle promised and delivered exciting human advances in space and benefits of space in people s everyday lives on earth. Johnson Space Center's Safety & Mission Assurance team work over the last 20 years has been mostly focused on operations we are now beginning the Exploration development program. S&MA will promote an atmosphere of knowledge sharing in its formal and informal cultures and work processes, and reward the open dissemination and sharing of information; we are asking "Why embrace relearning the "lessons learned" in the past?" On the Exploration program the focus will be on Design, Development, Test, & Evaluation (DDT&E); therefore, it is critical to understand the lessons from these past programs during the DDT&E phase.

  3. ESMD Risk Management Workshop: Systems Engineering and Integration Risks

    NASA Technical Reports Server (NTRS)

    Thomas, L. Dale

    2005-01-01

    This report has been developed by the National Aeronautics and Space Administration (NASA) Exploration Systems Mission Directorate (ESMD) Risk Management team in close coordination with the Systems Engineering Team. This document provides a point-in-time, cumulative, summary of key lessons learned derived from the SE RFP Development process. Lessons learned invariably address challenges and risks and the way in which these areas have been addressed. Accordingly the risk management thread is woven throughout the document.

  4. Family planning and sexual health organizations: management lessons for health system reform.

    PubMed

    Ambegaokar, Maia; Lush, Louisiana

    2004-10-01

    Advocates of health system reform are calling for, among other things, decentralized, autonomous managerial and financial control, use of contracting and incentives, and a greater reliance on market mechanisms in the delivery of health services. The family planning and sexual health (FP&SH) sector already has experience of these. In this paper, we set forth three typical means of service provision within the FP&SH sector since the mid-1900s: independent not-for-profit providers, vertical government programmes and social marketing programmes. In each case, we present the context within which the service delivery mechanism evolved, the management techniques that characterize it and the lessons learned in FP&SH that are applicable to the wider debate about improving health sector management. We conclude that the FP&SH sector can provide both positive and negative lessons in the areas of autonomous management, use of incentives to providers and acceptors, balancing of centralization against decentralization, and employing private sector marketing and distribution techniques for delivering health services. This experience has not been adequately acknowledged in the debates about how to improve the quality and quantity of health services for the poor in developing countries. Health sector reform advocates and FP&SH advocates should collaborate within countries and regions to apply these management lessons. Copyright 2004 Oxford University Press

  5. In Defense of Clinical Autopsy and Its Practice in Cuba.

    PubMed

    Espinosa-Brito, Alfredo D; de Mendoza-Amat, José Hurtado

    2017-01-01

    There has been a notable decrease in the global practice of clinical autopsy; the rate has fallen to below 10%, even in high-income countries. This is attributed to several causes, including increased costs, overreliance on modern diagnostic techniques, cultural and religious factors, the emergence of new infectious diseases and negative attitudes on the part of doctors, even pathologists. Alternative methods to autopsy in postmortem studies have been developed based on imaging, endoscopy and biopsy (all quite expensive). These methods have been used in developed countries but never as effectively as the classic autopsy for identifying cause of death and potential medical errors. Although Cuba has also seen a decrease in its autopsy rates, they remain comparatively high. Between 1996 and 2015, there were 687,689 hospital deaths in Cuba and 381,193 autopsies, 55.4% of the total. These autopsies have positively affected medical care, training, research, innovation, management and society as a whole. Autopsies are an important tool in the National Health System's quest for safe, quality patient care based on the lessons learned from studying the deceased. KEYWORDS Autopsy, postmortem examination, postmortem diagnosis, quality of care, patient safety, medical error, Cuba.

  6. Commentary on "Lessons Learned from Leading an Anger Management Group Using the "Seeing Red" Curriculum in an Elementary School"

    ERIC Educational Resources Information Center

    Hoover, Sally

    2010-01-01

    This commentary responds to "Lessons Learned From Leading an Anger Management Group Using the "Seeing Red" Curriculum in an Elementary School," E. L. Sportsman, J. S. Carlson, and K. M. Guthrie's (2010/this issue) account of an anger control intervention's implementation and effectiveness in an elementary school setting. The accompanying article…

  7. Pest Management and Environmental Quality. Course 181. Correspondence Courses in Agriculture, Family Living and Community Development.

    ERIC Educational Resources Information Center

    Cole, Herbert, Jr.; And Others

    This publication is the course book for a correspondence course in pest control with the Pennsylvania State University. It contains basic information for agricultural producers on pest management and the proper and safe use of pesticides. The course consists of eleven lessons which can be completed at one's leisure. The first nine lessons contain…

  8. Project Recon

    DTIC Science & Technology

    2012-06-14

    Management tool • Current Risk Recon functionality • Issues Recon & Opportunity Recon – Launching Fall 2012 • FMEA and Lessons Learned – Planned Future...Lessons learned UNCLASSIFIED Integrated Risk Management FMEA Failure Mode and Effects Analysis Risk Recon Fields from FMEA software pre...populate Risk Info sheet. Risk Mitigation from Risk Recon trace back and populate FMEA , new RPN numbers. Issues Recon When a risk becomes an issue

  9. Dealing with Power Games in a Companion Modelling Process: Lessons from Community Water Management in Thailand Highlands

    ERIC Educational Resources Information Center

    Barnaud, Cecile; van Paassen, Annemarie; Trebuil, Guy; Promburom, Tanya; Bousquet, Francois

    2010-01-01

    Although stakeholder participation is expected to promote equitable and sustainable natural resource management, lessons from the past tell us that more careful attention needs to be paid to achieving equitable impacts. Now the question is how to address social inequities and power asymmetries. Some authors emphasize the need for more dialogue,…

  10. Understanding human management of automation errors

    PubMed Central

    McBride, Sara E.; Rogers, Wendy A.; Fisk, Arthur D.

    2013-01-01

    Automation has the potential to aid humans with a diverse set of tasks and support overall system performance. Automated systems are not always reliable, and when automation errs, humans must engage in error management, which is the process of detecting, understanding, and correcting errors. However, this process of error management in the context of human-automation interaction is not well understood. Therefore, we conducted a systematic review of the variables that contribute to error management. We examined relevant research in human-automation interaction and human error to identify critical automation, person, task, and emergent variables. We propose a framework for management of automation errors to incorporate and build upon previous models. Further, our analysis highlights variables that may be addressed through design and training to positively influence error management. Additional efforts to understand the error management process will contribute to automation designed and implemented to support safe and effective system performance. PMID:25383042

  11. Understanding human management of automation errors.

    PubMed

    McBride, Sara E; Rogers, Wendy A; Fisk, Arthur D

    2014-01-01

    Automation has the potential to aid humans with a diverse set of tasks and support overall system performance. Automated systems are not always reliable, and when automation errs, humans must engage in error management, which is the process of detecting, understanding, and correcting errors. However, this process of error management in the context of human-automation interaction is not well understood. Therefore, we conducted a systematic review of the variables that contribute to error management. We examined relevant research in human-automation interaction and human error to identify critical automation, person, task, and emergent variables. We propose a framework for management of automation errors to incorporate and build upon previous models. Further, our analysis highlights variables that may be addressed through design and training to positively influence error management. Additional efforts to understand the error management process will contribute to automation designed and implemented to support safe and effective system performance.

  12. What is the perceived impact of Alexander technique lessons on health status, costs and pain management in the real life setting of an English hospital? The results of a mixed methods evaluation of an Alexander technique service for those with chronic back pain.

    PubMed

    McClean, Stuart; Brilleman, Sam; Wye, Lesley

    2015-07-28

    Randomised controlled trial evidence indicates that Alexander Technique is clinically and cost effective for chronic back pain. The aim of this mixed methods evaluation was to explore the role and perceived impact of Alexander Technique lessons in the naturalistic setting of an acute hospital Pain Management Clinic in England. To capture changes in health status and resource use amongst service users, 43 service users were administered three widely used questionnaires (Brief Pain Inventory, MYMOP and Client Service Resource Inventory) at three time points: baseline, six weeks and three months after baseline. We also carried out 27 telephone interviews with service users and seven face-to-face interviews with pain clinic staff and Alexander Technique teachers. Quantitative data were analysed using descriptive statistics and qualitative data were analysed thematically. Those taking Alexander Technique lessons reported small improvements in health outcomes, and condition-related costs fell. However, due to the non-randomised, uncontrolled nature of the study design, changes cannot be attributed to the Alexander Technique lessons. Service users stated that their relationship to pain and pain management had changed, especially those who were more committed to practising the techniques regularly. These changes may explain the reported reduction in pain-related service use and the corresponding lower associated costs. Alexander Technique lessons may be used as another approach to pain management. The findings suggests that Alexander Technique lessons can help improve self-efficacy for those who are sufficiently motivated, which in turn may have an impact on service utilisation levels.

  13. Effects of Lesson Study on Science Teacher Candidates' Teaching Efficacies

    ERIC Educational Resources Information Center

    Pektas, Murat

    2014-01-01

    The aim of this study was to investigate the effects of the lesson study process on science teacher candidates' teaching in terms of lesson plan content, pedagogy and classroom management based on expert, peer and self-evaluations. The participants of this case study consisted of 16 teacher candidates in elementary science education in their…

  14. Lesson Study to Scale up Research-Based Knowledge: A Randomized, Controlled Trial of Fractions Learning

    ERIC Educational Resources Information Center

    Lewis, Catherine; Perry, Rebecca

    2017-01-01

    An understanding of fractions eludes many U.S. students, and research-based knowledge about fraction, such as the utility of linear representations, has not broadly influenced instruction. This randomized trial of lesson study supported by mathematical resources assigned 39 educator teams across the United States to locally managed lesson study…

  15. Principles of disaster management lesson. 12: structuring organizations.

    PubMed

    Cuny, F C

    2001-01-01

    This lesson discusses various structures for organizations that have functional roles in disaster responses, relief, and/or management activities. It distinguishes between pyramidal and matrix structures, and notes the advantages and disadvantages of each in relation to disasters. Span of control issues are dissected including the impact of the "P" factor on the performance of disaster managers and workers including its relationship to the coordination and control function. The development of a Table of Organization and how it relates to departmentalization within an organization also is provided.

  16. Highlights of Total Quality Management in the Department of Defense: Lessons Learned, Quality Measurements and Innovative Practices

    DTIC Science & Technology

    1991-09-26

    Quality Management (TQM) through both quantitative and qualitative analyses. Interviews were conducted with top executives from ten exemplar organizations within the Department of Defense (DOD). Survey questionnaires on perceptions of quality practices were administered to a sample of 102 representing members of the executive steering committees at the same organizations. Research identifies lessons learned by top executives during TQM implementation, discusses measures of organization-wide quality management , specifies evaluation mechanisms to

  17. Understanding diagnostic errors in medicine: a lesson from aviation

    PubMed Central

    Singh, H; Petersen, L A; Thomas, E J

    2006-01-01

    The impact of diagnostic errors on patient safety in medicine is increasingly being recognized. Despite the current progress in patient safety research, the understanding of such errors and how to prevent them is inadequate. Preliminary research suggests that diagnostic errors have both cognitive and systems origins. Situational awareness is a model that is primarily used in aviation human factors research that can encompass both the cognitive and the systems roots of such errors. This conceptual model offers a unique perspective in the study of diagnostic errors. The applicability of this model is illustrated by the analysis of a patient whose diagnosis of spinal cord compression was substantially delayed. We suggest how the application of this framework could lead to potential areas of intervention and outline some areas of future research. It is possible that the use of such a model in medicine could help reduce errors in diagnosis and lead to significant improvements in patient care. Further research is needed, including the measurement of situational awareness and correlation with health outcomes. PMID:16751463

  18. Action errors, error management, and learning in organizations.

    PubMed

    Frese, Michael; Keith, Nina

    2015-01-03

    Every organization is confronted with errors. Most errors are corrected easily, but some may lead to negative consequences. Organizations often focus on error prevention as a single strategy for dealing with errors. Our review suggests that error prevention needs to be supplemented by error management--an approach directed at effectively dealing with errors after they have occurred, with the goal of minimizing negative and maximizing positive error consequences (examples of the latter are learning and innovations). After defining errors and related concepts, we review research on error-related processes affected by error management (error detection, damage control). Empirical evidence on positive effects of error management in individuals and organizations is then discussed, along with emotional, motivational, cognitive, and behavioral pathways of these effects. Learning from errors is central, but like other positive consequences, learning occurs under certain circumstances--one being the development of a mind-set of acceptance of human error.

  19. Employing Earned Value Management in Government Research and Design - Lessons Learned from the Trenches

    NASA Technical Reports Server (NTRS)

    Simon, Tom

    2009-01-01

    To effectively manage a project, the project manager must have a plan, understand the current conditions, and be able to take action to correct the course when challenges arise. Research and design projects face technical, schedule, and budget challenges that make it difficult to utilize project management tools developed for projects based on previously demonstrated technologies. Projects developing new technologies by their inherent nature are trying something new and thus have little to no data to support estimates for schedule and cost, let alone the technical outcome. Projects with a vision for the outcome but little confidence in the exact tasks to accomplish in order to achieve the vision incur cost and schedule penalties when conceptual solutions require unexpected iterations or even a reinvention of the plan. This presentation will share the project management methodology and tools developed through trial and error for a NASA research and design project combining industry, academia, and NASA inhouse work in which Earned Value Management principles were employed but adapted for the reality of the government financial system and the reality of challenging technology development. The priorities of the presented methodology are flexibility, accountability, and simplicity to give the manager tools to help deliver to the customer while not using up valuable time and resources on extensive planning and analysis. This presentation will share the methodology, tools, and work through failed and successful examples from the three years of process evolution.

  20. Use of after action reports (AARs) to promote organizational and systems learning in emergency preparedness.

    PubMed

    Savoia, Elena; Agboola, Foluso; Biddinger, Paul D

    2012-08-01

    Many public health and healthcare organizations use formal knowledge management practices to identify and disseminate the experiences gained over time. The "lessons-learned" approach is one such example of knowledge management practice applied to the wider concept of organizational learning. In the field of emergency preparedness, the lessons-learned approach stands on the assumption that learning from experience improves practice and minimizes avoidable deaths and negative economic and social consequences of disasters. In this project, we performed a structured review of AARs to analyze how lessons learned from the response to real-incidents may be used to maximize knowledge management and quality improvement practices such as the design of public health emergency preparedness (PHEP) exercises. We chose as a source of data the "Lessons Learned Information Sharing (LLIS.gov)" system, a joined program of the U.S. Department of Homeland Security DHS and FEMA that serves as the national, online repository of lessons learned, best practices, and innovative ideas. We identified recurring challenges reported by various states and local public health agencies in the response to different types of incidents. We also strove to identify the limitations of systematic learning that can be achieved due to existing weaknesses in the way AARs are developed.

  1. Use of After Action Reports (AARs) to Promote Organizational and Systems Learning in Emergency Preparedness

    PubMed Central

    Savoia, Elena; Agboola, Foluso; Biddinger, Paul D.

    2012-01-01

    Many public health and healthcare organizations use formal knowledge management practices to identify and disseminate the experiences gained over time. The “lessons-learned” approach is one such example of knowledge management practice applied to the wider concept of organizational learning. In the field of emergency preparedness, the lessons-learned approach stands on the assumption that learning from experience improves practice and minimizes avoidable deaths and negative economic and social consequences of disasters. In this project, we performed a structured review of AARs to analyze how lessons learned from the response to real-incidents may be used to maximize knowledge management and quality improvement practices such as the design of public health emergency preparedness (PHEP) exercises. We chose as a source of data the “Lessons Learned Information Sharing (LLIS.gov)” system, a joined program of the U.S. Department of Homeland Security DHS and FEMA that serves as the national, online repository of lessons learned, best practices, and innovative ideas. We identified recurring challenges reported by various states and local public health agencies in the response to different types of incidents. We also strived to identify the limitations of systematic learning that can be achieved due to existing weaknesses in the way AARs are developed. PMID:23066408

  2. Lessons Learned from the Node 1 Atmosphere Control and Storage and Water Recovery and Management Subsystem Design

    NASA Technical Reports Server (NTRS)

    Williams, David E.

    2010-01-01

    Node 1 flew to the International Space Station (ISS) on Flight 2A during December 1998. To date the National Aeronautics and Space Administration (NASA) has learned a lot of lessons from this module based on its history of approximately two years of acceptance testing on the ground and currently its twelve years on-orbit. This paper will provide an overview of the ISS Environmental Control and Life Support (ECLS) design of the Node 1 Atmosphere Control and Storage (ACS) and Water Recovery and Management (WRM) subsystems and it will document some of the lessons that have been learned to date for these subsystems based on problems prelaunch, problems encountered on-orbit, and operational problems/concerns. It is hoped that documenting these lessons learned from ISS will help in preventing them in future Programs.

  3. Lessons Learned from the Node 1 Atmosphere Control and Storage and Water Recovery and Management Subsystem Design

    NASA Technical Reports Server (NTRS)

    Williams, David E.

    2011-01-01

    Node 1 flew to the International Space Station (ISS) on Flight 2A during December 1998. To date the National Aeronautics and Space Administration (NASA) has learned a lot of lessons from this module based on its history of approximately two years of acceptance testing on the ground and currently its twelve years on-orbit. This paper will provide an overview of the ISS Environmental Control and Life Support (ECLS) design of the Node 1 Atmosphere Control and Storage (ACS) and Water Recovery and Management (WRM) subsystems and it will document some of the lessons that have been learned to date for these subsystems based on problems prelaunch, problems encountered on-orbit, and operational problems/concerns. It is hoped that documenting these lessons learned from ISS will help in preventing them in future Programs.

  4. Towards evidence-based management: creating an informative database of nursing-sensitive indicators.

    PubMed

    Patrician, Patricia A; Loan, Lori; McCarthy, Mary; Brosch, Laura R; Davey, Kimberly S

    2010-12-01

    The purpose of this paper is to describe the creation, evolution, and implementation of a database of nursing-sensitive and potentially nursing-sensitive indicators, the Military Nursing Outcomes Database (MilNOD). It discusses data quality, utility, and lessons learned. Prospective data collected each shift include direct staff hours by levels (i.e., registered nurse, other licensed and unlicensed providers), staff categories (i.e., military, civilian, contract, and reservist), patient census, acuity, and admissions, discharges, and transfers. Retrospective adverse event data (falls, medication errors, and needle-stick injuries) were collected from existing records. Annual patient satisfaction, nurse work environment, and pressure ulcer and restraint prevalence surveys were conducted. The MilNOD contains shift level data from 56 units in 13 military hospitals and is used to target areas for managerial and clinical performance improvement. This methodology can be modified for use in other healthcare systems. As standard tools for evidence-based management, databases such as MilNOD allow nurse leaders to track the status of nursing and adverse events in their facilities. No claim to original US government works.

  5. Lesson Plans for Teaching Basic Vocational Agriculture. Section III. Introduction to Soil Management and Classification.

    ERIC Educational Resources Information Center

    McCully, James S., Jr., Comp.

    This publication, one of five sections, was developed for use in first and second year basic agriculture courses in secondary schools in Mississippi. The five lessons focus on the measurement and description of property and the classification of land. The purposes of the lessons are to (1) introduce the units and methods used to measure distance…

  6. Encouraging Problem-Solving Disposition in a Singapore Classroom

    ERIC Educational Resources Information Center

    Leong, Yew Hoong; Yap, Sook Fwe; Quek, Khiok Seng; Tay, Eng Guan; Tong, Cherng Luen; Ong, Yao Teck; Chia, Alexander Stanley Foh Soon; Zaini, Irni Karen Mohd; Khong, Wee Choo; Lock, Oi Leng; Zhang, Qiao Tian Beatrice; Tham, Yi Hui; Noorhazman, Nur-Illya Nafiza Mohamed

    2013-01-01

    In this article, we share our learning experience as a Lesson Study team. The Research Lesson was on Figural Patterns taught in Year 7. In addition to helping students learn the skills of the topic, we wanted them to develop a problem-solving disposition. The management of these two objectives was a challenge to us. From the lesson observation and…

  7. 2000 Worldwide Joint Lessons Learned Conference. Forging a Future Joint Lessons Learned System. (Joint Center for Lessons Learned Special Bulletin. Volume 3, Special Issue 1, January 2001)

    DTIC Science & Technology

    2001-01-01

    Management System (JTIMS) followed, and generated spirited discussion regarding the respective roles of JTIMS and the JLLP. The discussion concluded...waiting for the Director, Joint Staff�s signature and should be in official distribution by January 2001. An update on the Joint Training Information

  8. Strategic career planning for physician-scientists.

    PubMed

    Shimaoka, Motomu

    2015-05-01

    Building a successful professional career in the physician-scientist realm is rewarding but challenging, especially in the dynamic and competitive environment of today's modern society. This educational review aims to provide readers with five important career development lessons drawn from the business and social science literatures. Lessons 1-3 describe career strategy, with a focus on promoting one's strengths while minimizing fixing one's weaknesses (Lesson 1); effective time management in the pursuit of long-term goals (Lesson 2); and the intellectual flexibility to abandon/modify previously made decisions while embracing emerging opportunities (Lesson 3). Lesson 4 explains how to maximize the alternative benefits of English-language fluency (i.e., functions such as signaling and cognition-enhancing capabilities). Finally, Lesson 5 discusses how to enjoy happiness and stay motivated in a harsh, zero-sum game society.

  9. The evolution of Crew Resource Management training in commercial aviation

    NASA Technical Reports Server (NTRS)

    Helmreich, R. L.; Merritt, A. C.; Wilhelm, J. A.

    1999-01-01

    In this study, we describe changes in the nature of Crew Resource Management (CRM) training in commercial aviation, including its shift from cockpit to crew resource management. Validation of the impact of CRM is discussed. Limitations of CRM, including lack of cross-cultural generality are considered. An overarching framework that stresses error management to increase acceptance of CRM concepts is presented. The error management approach defines behavioral strategies taught in CRM as error countermeasures that are employed to avoid error, to trap errors committed, and to mitigate the consequences of error.

  10. Lost in Translation: the Case for Integrated Testing

    NASA Technical Reports Server (NTRS)

    Young, Aaron

    2017-01-01

    The building of a spacecraft is complex and often involves multiple suppliers and companies that have their own designs and processes. Standards have been developed across the industries to reduce the chances for critical flight errors at the system level, but the spacecraft is still vulnerable to the introduction of critical errors during integration of these systems. Critical errors can occur at any time during the process and in many cases, human reliability analysis (HRA) identifies human error as a risk driver. Most programs have a test plan in place that is intended to catch these errors, but it is not uncommon for schedule and cost stress to result in less testing than initially planned. Therefore, integrated testing, or "testing as you fly," is essential as a final check on the design and assembly to catch any errors prior to the mission. This presentation will outline the unique benefits of integrated testing by catching critical flight errors that can otherwise go undetected, discuss HRA methods that are used to identify opportunities for human error, lessons learned and challenges over ownership of testing will be discussed.

  11. Strategic National HRD Initiatives: Lessons from the Management Training Program of Japan. [and] Invited Reaction: The Little-Known Impact of U.S. Training Programs on the Japanese Quality Movement. [and] Invited Reaction: Comments on Strategic National Initiatives: Lessons from the Management Training Program of Japan.

    ERIC Educational Resources Information Center

    Robinson, Alan G.; And Others

    1995-01-01

    Robinson and Stern describe the Management Training Program introduced by the U.S. Air Force in postwar Japan and its effect on Japanese industry. Roberts compares it with U.S. Training within Industries. Umetani comments that the discussion would have been more convincing had its relationship with other Japanese training programs been addressed.…

  12. Lessons learned from KSC processing on STS science, applications, and commercial payloads

    NASA Technical Reports Server (NTRS)

    Williams, W. E.; Ragusa, J. M.

    1984-01-01

    The present investigation is concerned with an evaluation of the lessons learned in connection with the flights of the Shuttle orbiters Columbia, Challenger, and Discovery. A description is provided of several general and specific lessons related to the processing of free-flying and attached payloads. John F. Kennedy Space Center (KSC), as the prime launch and landing site, is responsible for managing all payload-to-payload, payload-to-simulated orbiter, and payload-to-orbiter operations. For each payload, a KSC Launch Site Support Manager (LSSM) is named as the primary point of contact for the customer. Attention is given to aspects of planning interaction, payload types, and problems of ground processing. The discussed lessons are partly related to the value of early contact between customers and KSC representatives, the primary point of contact, the launch site support plan, and the importance of customer participation.

  13. The Microcomputerization of Business Schools. Part I: General Strategies, Lessons, and Issues. Part II: A Case Study of the UCLA Graduate School of Management.

    ERIC Educational Resources Information Center

    Frand, Jason L.

    Part I (General Strategies, Lessons and Issues) of this two-part analysis of the microcomputerization process describes strategies schools have followed in their microcomputerization efforts and the lessons and issues that have emerged. Part I covers the following: strategies for introducing microcomputers into the curriculum (the saturation,…

  14. Managing an Infectious Disease Outbreak in a School. Lessons Learned from School Crises and Emergencies. Volume 2, Issue 3

    ERIC Educational Resources Information Center

    US Department of Education, 2007

    2007-01-01

    "Lessons Learned" is a series of publications that are a brief recounting of actual school emergencies and crises. This "Lessons Learned" issue focuses on an infectious disease incident, which resulted in the death of a student, closure of area schools and the operation of an on-site school vaccine clinic. The report highlights the critical need…

  15. Innovation Implementation in the Context of Hospital QI: Lessons Learned and Strategies for Success

    PubMed Central

    Rangachari, Pavani

    2018-01-01

    In 1999, the Institute of Medicine reported that 98,000 people die each year due to medical errors. In the following years, the focus on hospital quality was intensified nationally, with policymakers providing evidence-based practice guidelines for improving health care quality. However, these innovations (evidence-based guidelines) that were being produced at policy levels were not translating to clinical practice at the hospital organizational level easily, and stark variations continued to persist, in the quality of health care. Circa 2009, nearly a decade after the release of the IOM report, the health care organizational literature began referring to this challenge as “innovation implementation failure” in health care organizations (HCOs), ie, failure to implement an evidence-based practice that is new to a HCO. This stream of literature drew upon management research to explain why innovation implementation failure occurs in HCOs and what could be done to prevent it. This paper conducts an integrative review of the literature on “innovation implementation” in hospitals and health systems over the last decade, since the spotlight was cast on “innovation implementation failure” in HCOs. The review reveals that while some studies have retrospectively sought to identify the key drivers of innovation implementation, through surveys and interviews of practitioners (the “what”), other studies have prospectively sought to understand how innovation implementation occurs in hospitals and health systems (the “how”). Both make distinctive contributions to identifying strategies for success in innovation implementation. While retrospective studies have helped identify the key drivers of innovation implementation, prospective studies have shed light on how these drivers could be attained, thereby helping to develop context-sensitive management strategies for success. The literature has called for more prospective research on the implementation and sustainability of health care innovations. This paper summarizes the lessons learned from the literature, discusses the relevance of management research on innovation implementation in HCOs, and identifies future research avenues. PMID:29546884

  16. Innovation Implementation in the Context of Hospital QI: Lessons Learned and Strategies for Success.

    PubMed

    Rangachari, Pavani

    2018-01-01

    In 1999, the Institute of Medicine reported that 98,000 people die each year due to medical errors. In the following years, the focus on hospital quality was intensified nationally, with policymakers providing evidence-based practice guidelines for improving health care quality. However, these innovations (evidence-based guidelines) that were being produced at policy levels were not translating to clinical practice at the hospital organizational level easily, and stark variations continued to persist, in the quality of health care. Circa 2009, nearly a decade after the release of the IOM report, the health care organizational literature began referring to this challenge as "innovation implementation failure" in health care organizations (HCOs), ie, failure to implement an evidence-based practice that is new to a HCO. This stream of literature drew upon management research to explain why innovation implementation failure occurs in HCOs and what could be done to prevent it. This paper conducts an integrative review of the literature on "innovation implementation" in hospitals and health systems over the last decade, since the spotlight was cast on "innovation implementation failure" in HCOs. The review reveals that while some studies have retrospectively sought to identify the key drivers of innovation implementation, through surveys and interviews of practitioners (the "what"), other studies have prospectively sought to understand how innovation implementation occurs in hospitals and health systems (the "how"). Both make distinctive contributions to identifying strategies for success in innovation implementation. While retrospective studies have helped identify the key drivers of innovation implementation, prospective studies have shed light on how these drivers could be attained, thereby helping to develop context-sensitive management strategies for success. The literature has called for more prospective research on the implementation and sustainability of health care innovations. This paper summarizes the lessons learned from the literature, discusses the relevance of management research on innovation implementation in HCOs, and identifies future research avenues.

  17. Error management for musicians: an interdisciplinary conceptual framework

    PubMed Central

    Kruse-Weber, Silke; Parncutt, Richard

    2014-01-01

    Musicians tend to strive for flawless performance and perfection, avoiding errors at all costs. Dealing with errors while practicing or performing is often frustrating and can lead to anger and despair, which can explain musicians’ generally negative attitude toward errors and the tendency to aim for flawless learning in instrumental music education. But even the best performances are rarely error-free, and research in general pedagogy and psychology has shown that errors provide useful information for the learning process. Research in instrumental pedagogy is still neglecting error issues; the benefits of risk management (before the error) and error management (during and after the error) are still underestimated. It follows that dealing with errors is a key aspect of music practice at home, teaching, and performance in public. And yet, to be innovative, or to make their performance extraordinary, musicians need to risk errors. Currently, most music students only acquire the ability to manage errors implicitly – or not at all. A more constructive, creative, and differentiated culture of errors would balance error tolerance and risk-taking against error prevention in ways that enhance music practice and music performance. The teaching environment should lay the foundation for the development of such an approach. In this contribution, we survey recent research in aviation, medicine, economics, psychology, and interdisciplinary decision theory that has demonstrated that specific error-management training can promote metacognitive skills that lead to better adaptive transfer and better performance skills. We summarize how this research can be applied to music, and survey-relevant research that is specifically tailored to the needs of musicians, including generic guidelines for risk and error management in music teaching and performance. On this basis, we develop a conceptual framework for risk management that can provide orientation for further music education and musicians at all levels. PMID:25120501

  18. Error management for musicians: an interdisciplinary conceptual framework.

    PubMed

    Kruse-Weber, Silke; Parncutt, Richard

    2014-01-01

    Musicians tend to strive for flawless performance and perfection, avoiding errors at all costs. Dealing with errors while practicing or performing is often frustrating and can lead to anger and despair, which can explain musicians' generally negative attitude toward errors and the tendency to aim for flawless learning in instrumental music education. But even the best performances are rarely error-free, and research in general pedagogy and psychology has shown that errors provide useful information for the learning process. Research in instrumental pedagogy is still neglecting error issues; the benefits of risk management (before the error) and error management (during and after the error) are still underestimated. It follows that dealing with errors is a key aspect of music practice at home, teaching, and performance in public. And yet, to be innovative, or to make their performance extraordinary, musicians need to risk errors. Currently, most music students only acquire the ability to manage errors implicitly - or not at all. A more constructive, creative, and differentiated culture of errors would balance error tolerance and risk-taking against error prevention in ways that enhance music practice and music performance. The teaching environment should lay the foundation for the development of such an approach. In this contribution, we survey recent research in aviation, medicine, economics, psychology, and interdisciplinary decision theory that has demonstrated that specific error-management training can promote metacognitive skills that lead to better adaptive transfer and better performance skills. We summarize how this research can be applied to music, and survey-relevant research that is specifically tailored to the needs of musicians, including generic guidelines for risk and error management in music teaching and performance. On this basis, we develop a conceptual framework for risk management that can provide orientation for further music education and musicians at all levels.

  19. Medicine and aviation: a review of the comparison.

    PubMed

    Randell, R

    2003-01-01

    This paper aims to understand the nature of medical error in highly technological environments and argues that a comparison with aviation can blur its real understanding. This study is a comparative study between the notion of error in health care and aviation based on the author's own ethnographic study in intensive care units and findings from the research literature on errors in aviation. Failures in the use of medical technology are common. In attempts to understand the area of medical error, much attention has focused on how we can learn from aviation. This paper argues that such a comparison is not always useful, on the basis that (i) the type of work and technology is very different in the two domains; (ii) different issues are involved in training and procurement; and (iii) attitudes to error vary between the domains. Therefore, it is necessary to look closely at the subject of medical error and resolve those questions left unanswered by the lessons of aviation.

  20. Rater Drift and Time Trends in Classroom Observations

    ERIC Educational Resources Information Center

    Casabianca, Jodi M.; Lockwood, J. R.

    2013-01-01

    Classroom observation protocols, in which observers rate multiple dimensions of teaching according to established protocols (either live in the classroom, or post-hoc from lesson videos), are increasingly being used in both research and policy contexts. However, scores generated from these protocols have many sources of error. Day to day variation…

  1. Collaborative Repair in EFL Classroom Talk.

    ERIC Educational Resources Information Center

    Iles, Zara

    1996-01-01

    Drawing data from audiotaped lessons with 10 native-speaker English-as-a-Foreign-Language (EFL) teachers and 12 EFL learners of varied linguistic backgrounds, a study explored some of the ways in which classroom talk by learners is collaboratively built to repair errors, misunderstandings, and non-communication. Focus is on both explicit and…

  2. Integrated Risk and Knowledge Management Program -- IRKM-P

    NASA Technical Reports Server (NTRS)

    Lengyel, David M.

    2009-01-01

    The NASA Exploration Systems Mission Directorate (ESMD) IRKM-P tightly couples risk management and knowledge management processes and tools to produce an effective "modern" work environment. IRKM-P objectives include: (1) to learn lessons from past and current programs (Apollo, Space Shuttle, and the International Space Station); (2) to generate and share new engineering design, operations, and management best practices through preexisting Continuous Risk Management (CRM) procedures and knowledge-management practices; and (3) to infuse those lessons and best practices into current activities. The conceptual framework of the IRKM-P is based on the assumption that risks highlight potential knowledge gaps that might be mitigated through one or more knowledge management practices or artifacts. These same risks also serve as cues for collection of knowledge particularly, knowledge of technical or programmatic challenges that might recur.

  3. Putting into practice error management theory: Unlearning and learning to manage action errors in construction.

    PubMed

    Love, Peter E D; Smith, Jim; Teo, Pauline

    2018-05-01

    Error management theory is drawn upon to examine how a project-based organization, which took the form of a program alliance, was able to change its established error prevention mindset to one that enacted a learning mindfulness that provided an avenue to curtail its action errors. The program alliance was required to unlearn its existing routines and beliefs to accommodate the practices required to embrace error management. As a result of establishing an error management culture the program alliance was able to create a collective mindfulness that nurtured learning and supported innovation. The findings provide a much-needed context to demonstrate the relevance of error management theory to effectively address rework and safety problems in construction projects. The robust theoretical underpinning that is grounded in practice and presented in this paper provides a mechanism to engender learning from errors, which can be utilized by construction organizations to improve the productivity and performance of their projects. Copyright © 2018 Elsevier Ltd. All rights reserved.

  4. What tourist business managers must learn from disaster research.

    PubMed

    Drabek, Thomas E

    2016-01-01

    Death and social disruption caused by disasters of varying forms will continue to increase in the future. So too will the impacts on tourism, now one of the fastest growing and largest sectors of the worldwide economy. Tourist business managers must implement evidence-based preparedness activities to enhance the survival potential and future profitability of their firms. Drawing upon recent research studies of the tourist industry during times of crisis and the broad social science knowledge base regarding human responses to disaster, seven key lessons are described. Emergency managers must facilitate the incorporation of these lessons into the culture of tourist business managers.

  5. Lessons Learned in the D.C. Public Schools. Hearing before the Subcommittee on Oversight of Government Management, Restructuring, and the District of Columbia of the Committee on Governmental Affairs. United States Senate, One Hundred Fifth Congress. Second Session (March 9, 1998).

    ERIC Educational Resources Information Center

    Congress of the U.S., Washington, DC. Senate Committee on Governmental Affairs.

    The focus of this hearing was on lessons learned in the District of Columbia public schools in the year preceding the hearing. In his opening remarks, Senator Brownback (Kansas) remarked that one of the first lessons is that the academic quality of the schools is not good enough and is in dire need of improvement. A second set of lessons focuses…

  6. Risk managers, physicians, and disclosure of harmful medical errors.

    PubMed

    Loren, David J; Garbutt, Jane; Dunagan, W Claiborne; Bommarito, Kerry M; Ebers, Alison G; Levinson, Wendy; Waterman, Amy D; Fraser, Victoria J; Summy, Elizabeth A; Gallagher, Thomas H

    2010-03-01

    Physicians are encouraged to disclose medical errors to patients, which often requires close collaboration between physicians and risk managers. An anonymous national survey of 2,988 healthcare facility-based risk managers was conducted between November 2004 and March 2005, and results were compared with those of a previous survey (conducted between July 2003 and March 2004) of 1,311 medical physicians in Washington and Missouri. Both surveys included an error-disclosure scenario for an obvious and a less obvious error with scripted response options. More risk managers than physicians were aware that an error-reporting system was present at their hospital (81% versus 39%, p < .001) and believed that mechanisms to inform physicians about errors in their hospital were adequate (51% versus 17%, p < .001). More risk managers than physicians strongly agreed that serious errors should be disclosed to patients (70% versus 49%, p < .001). Across both error scenario, risk managers were more likely than physicians to definitely recommend that the error be disclosed (76% versus 50%, p < .001) and to provide full details about how the error would be prevented in the future (62% versus 51%, p < .001). However, physicians were more likely than risk managers to provide a full apology recognizing the harm caused by the error (39% versus 21%, p < .001). Risk managers have more favorable attitudes about disclosing errors to patients compared with physicians but are less supportive of providing a full apology. These differences may create conflicts between risk managers and physicians regarding disclosure. Health care institutions should promote greater collaboration between these two key participants in disclosure conversations.

  7. Project management lessons learned on SDIO's Delta Star and Single Stage Rocket Technology programs

    NASA Technical Reports Server (NTRS)

    Klevatt, Paul L.

    1992-01-01

    The topics are presented in viewgraph form and include the following: a Delta Star (Delta 183) Program Overview, lessons learned, and rapid prototyping and the Single Stage Rocket Technology (SSRT) Program. The basic objective of the Strategic Defense Initiative Programs are to quickly reduce key uncertainties to a manageable range of parameters and solutions, and to yield results applicable to focusing subsequent research dollars on high payoff areas.

  8. Telematics Framework for Federal Agencies: Lessons from the Marine Corps Fleet

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Hodge, Cabell; Singer, Mark R.

    Executive Order 13693 requires federal agencies to acquire telematics for their light- and medium-duty vehicles as appropriate. This report is intended to help agencies that are deploying telematics systems and seeking to integrate them into their fleet management process. It provides an overview of telematics capabilities, lessons learned from the deployment of telematics in the Marine Corps fleet, and recommendations for federal fleet managers to maximize value from telematics.

  9. Application of Education Management and Lesson Study in Teaching Mathematics to Students of Second Grade of Public School in District 3 of Tehran

    ERIC Educational Resources Information Center

    Farhoush, Masoumeh; Majedi, Parisima; Behrangi, Mohammadreza

    2017-01-01

    The present paper studies the effects of lesson study as a sample of participative researches in classroom as well as Behrangi Education Management Model in courses by aiming at exploring and allowing students to use the indexes of course concepts as an effective model in learning. The research plan is pre-test, posttest with control group type.…

  10. LESSONS LEARNED Biosurveillance Mobile App Development Intern Competition (Summer 2013)

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Noonan, Christine F.; Henry, Michael J.; Corley, Courtney D.

    2014-01-14

    The purpose of the lessons learned document for the BEOWulf Biosurveillance Mobile App Development Intern Competition is to capture the project’s lessons learned in a formal document for use by other project managers on similar future projects. This document may be used as part of new project planning for similar projects in order to determine what problems occurred and how those problems were handled and may be avoided in the future. Additionally, this document details what went well with the project and why, so that other project managers may capitalize on these actions. Project managers may also use this documentmore » to determine who the project team members were in order to solicit feedback for planning their projects in the future. This document will be formally communicated with the organization and will become a part of the organizational assets and archives.« less

  11. Toward a best practice model for managed lanes in Texas.

    DOT National Transportation Integrated Search

    2013-09-01

    Increasing implementation of managed lanes in the : United States : Katy Freeway Managed Lanes : (KML) offers lessons learned : for other projects : First operational, multilane, : variably priced, managed facility : in Texas : Became oper...

  12. Lessons learned from case studies of inhalation exposures of workers to radioactive aerosols

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Hoover, M.D.; Fencl, A.F.; Newton, G.J.

    1995-12-01

    Various Department of Energy requirements, rules, and orders mandate that lessons learned be identified, evaluated, shared, and incorporated into current practices. The recently issued, nonmandatory DOE standard for Development of DOE Lessons Learned Program states that a DOE-wide lessons learned program will {open_quotes}help to prevent recurrences of negative experiences, highlight best practices, and spotlight innovative ways to solve problems or perform work more safely, efficiently, and cost effectively.{close_quotes} Additional information about the lessons learned program is contained in the recently issued DOE handbook on Implementing U.S. Department of Energy Lessons Learned Programs and in October 1995 DOE SAfety Notice onmore » Lessons Learned Programs. This report summarizes work in progress at ITRI to identify lessons learned for worker exposures to radioactive aerosols, and describes how this work will be incorporated into the DOE lessons learned program, including a new technical guide for measuring, modeling, and mitigating airborne radioactive particles. Follow-on work is focusing on preparation of {open_quotes}lessons learned{close_quotes} training materials for facility designers, managers, health protection professionals, line supervisors, and workers.« less

  13. Apollo 1 Lessons Learned Show

    NASA Image and Video Library

    2017-01-27

    Mike Ciannilli, at left, the Apollo, Challenger, Columbia Lessons Learned Program manager, presents a certificate to John Tribe, retired, Apollo 1 Reaction and Control System lead engineer, during the Apollo 1 Lessons Learned presentation in the Training Auditorium at NASA's Kennedy Space Center in Florida. The theme of the program was "To there and Back Again." The event helped pay tribute to the Apollo 1 crew, Gus Grissom, Ed White II, and Roger Chaffee.

  14. Agricultural Marketing.

    ERIC Educational Resources Information Center

    Helt, Lawrence; And Others

    Designed for use in farm business management adult programs, this marketing curriculum includes six teaching lessons and professional staff products. The following topics are covered in the lessons: introduction to marketing; interpretation of price/demand/supply cycles and fundamental outlook trends (carryover/projections/disappearance); farmers'…

  15. Stopping Discipline Problems before They Start.

    ERIC Educational Resources Information Center

    VanDerveer, Elizabeth

    1989-01-01

    States that prevention of discipline problems is directly related to effective teaching strategies. Suggests that good teaching, based on well-planned lessons, proper pacing of lessons, effective classroom management, teacher assertiveness, and teacher musicality, can prevent undesirable behaviors in the music classroom. (LS)

  16. Critical elements and lessons learnt from the implementation of an RFID-enabled healthcare management system in a medical organization.

    PubMed

    Ting, S L; Kwok, S K; Tsang, Albert H C; Lee, W B

    2011-08-01

    Healthcare services are complex and life-critical. One mistake in any procedure may lead to irremediable consequences; numerous researchers, thus, introduce information and communication technology to improve quality of services and enhance patient safety by reducing the medical errors. Radio frequency identification (RFID) is considered as one of the emerging tool assist in meeting the challenges of the present situation. In recent years, RFID has been applied in medical organizations for the purpose of managing and tracking medical equipment, monitoring and identifying patients, ensuring that the right medication is given to the right patient, and preventing the use of counterfeit medicine. However, most of the existing literature focuses on demonstrating how RFID can benefit the healthcare industry, whereas little attention has been given to the management issues involved in constructing an RFID project in medical organizations. In this paper, an exploratory case study is conducted in a medical organization to illustrate the development framework and critical issues that should be taken into consideration in the preparation, implementation and maintenance stage of constructing such a project. All the experiences and results discussed in this paper offer valuable and useful insights to steer those who would like to start their journey using RFID in medical organizations.

  17. Management of change for nurses: lessons from the discipline of organizational studies.

    PubMed

    Shanley, Chris

    2007-07-01

    This paper explores the literature on change management from the discipline of organizational studies to provide insights that nurse managers can use in their professional practice. The paper will benefit nurse managers by extending the nursing discourse on change management to include wider theoretical and academic perspectives. Important aspects of change management explored are the roles of power and political behaviour, how much change can be planned and controlled, how to combine top-down and bottom-up approaches to change, the role of emotions in the change management process, a comparison of prescriptive and analytical approaches to understanding change, and the connection between theory and practice in managing change. While nurses can draw much useful information from within the nursing discipline, they can also benefit by exploring other disciplinary areas. In the case of change management, there are many useful lessons nurses can carry over into their professional practice.

  18. Managing harvest and habitat as integrated components

    USGS Publications Warehouse

    Osnas, Erik; Runge, Michael C.; Mattsson, Brady J.; Austin, Jane E.; Boomer, G. S.; Clark, R. G.; Devers, P.; Eadie, J. M.; Lonsdorf, E. V.; Tavernia, Brian G.

    2014-01-01

    In 2007, several important initiatives in the North American waterfowl management community called for an integrated approach to habitat and harvest management. The essence of the call for integration is that harvest and habitat management affect the same resources, yet exist as separate endeavours with very different regulatory contexts. A common modelling framework could help these management streams to better understand their mutual effects. Particularly, how does successful habitat management increase harvest potential? Also, how do regional habitat programmes and large-scale harvest strategies affect continental population sizes (a metric used to express habitat goals)? In the ensuing five years, several projects took on different aspects of these challenges. While all of these projects are still on-going, and are not yet sufficiently developed to produce guidance for management decisions, they have been influential in expanding the dialogue and producing some important emerging lessons. The first lesson has been that one of the more difficult aspects of integration is not the integration across decision contexts, but the integration across spatial and temporal scales. Habitat management occurs at local and regional scales. Harvest management decisions are made at a continental scale. How do these actions, taken at different scales, combine to influence waterfowl population dynamics at all scales? The second lesson has been that consideration of the interface of habitat and harvest management can generate important insights into the objectives underlying the decision context. Often the objectives are very complex and trade-off against one another. The third lesson follows from the second – if an understanding of the fundamental objectives is paramount, there is no escaping the need for a better understanding of human dimensions, specifically the desires of hunters and nonhunters and the role they play in conservation. In the end, the compelling question is how to better understand, guide and justify decisions about conservation investments in waterfowl management. Future efforts to integrate harvest and habitat management will include completion of the species-specific case-studies, initiation of policy discussions around how to integrate the decision contexts and governing institutions, and possible consideration of a new level of integration – integration of harvest and habitats management decisions across waterfowl stocks.

  19. Ares Knowledge Capture: Summary and Key Themes Presentation

    NASA Technical Reports Server (NTRS)

    Coates, Ralph H.

    2011-01-01

    This report has been developed by the National Aeronautics and Space Administration (NASA) Human Exploration and Operations Mission Directorate (HEOMD) Risk Management team in close coordination with the MSFC Chief Engineers Office. This document provides a point-in-time, cumulative, summary of actionable key lessons learned derived from the design project. Lessons learned invariably address challenges and risks and the way in which these areas have been addressed. Accordingly the risk management thread is woven throughout the document.

  20. The Status of Ubiquitous Computing.

    ERIC Educational Resources Information Center

    Brown, David G.; Petitto, Karen R.

    2003-01-01

    Explains the prevalence and rationale of ubiquitous computing on college campuses--teaching with the assumption or expectation that all faculty and students have access to the Internet--and offers lessons learned by pioneering institutions. Lessons learned involve planning, technology, implementation and management, adoption of computer-enhanced…

  1. Defining a risk-informed framework for whole-of-government lessons learned: A Canadian perspective.

    PubMed

    Friesen, Shaye K; Kelsey, Shelley; Legere, J A Jim

    Lessons learned play an important role in emergency management (EM) and organizational agility. Virtually all aspects of EM can derive benefit from a lessons learned program. From major security events to exercises, exploiting and applying lessons learned and "best practices" is critical to organizational resilience and adaptiveness. A robust lessons learned process and methodology provides an evidence base with which to inform decisions, guide plans, strengthen mitigation strategies, and assist in developing tools for operations. The Canadian Safety and Security Program recently supported a project to define a comprehensive framework that would allow public safety and security partners to regularly share event response best practices, and prioritize recommendations originating from after action reviews. This framework consists of several inter-locking elements: a comprehensive literature review/environmental scan of international programs; a survey to collect data from end users and management; the development of a taxonomy for organizing and structuring information; a risk-informed methodology for selecting, prioritizing, and following through on recommendations; and standardized templates and tools for tracking recommendations and ensuring implementation. This article discusses the efforts of the project team, which provided "best practice" advice and analytical support to ensure that a systematic approach to lessons learned was taken by the federal community to improve prevention, preparedness, and response activities. It posits an approach by which one might design a systematic process for information sharing and event response coordination-an approach that will assist federal departments to institutionalize a cross-government lessons learned program.

  2. Checking the Grammar Checker: Integrating Grammar Instruction with Writing.

    ERIC Educational Resources Information Center

    McAlexander, Patricia J.

    2000-01-01

    Notes Rei Noguchi's recommendation of integrating grammar instruction with writing instruction and teaching only the most vital terms and the most frequently made errors. Presents a project that provides a review of the grammar lessons, applies many grammar rules specifically to the students' writing, and teaches students the effective use of the…

  3. Benefits of Hybrid Classes in Community Colleges

    ERIC Educational Resources Information Center

    Barker, Joel

    2015-01-01

    This article discusses hybrid courses and their impact on educational facilities, their students, and instructors. Instructors now have over ten years of data related to hybrid courses and by trial and error have devised different strategies to plan and execute lesson plans via partly online forums. Programs are in place that give students the…

  4. Kitchen Physics: Lessons in Fluid Pressure and Error Analysis

    ERIC Educational Resources Information Center

    Vieyra, Rebecca Elizabeth; Vieyra, Chrystian; Macchia, Stefano

    2017-01-01

    Although the advent and popularization of the "flipped classroom" tends to center around at-home video lectures, teachers are increasingly turning to at-home labs for enhanced student engagement. This paper describes two simple at-home experiments that can be accomplished in the kitchen. The first experiment analyzes the density of four…

  5. Current Trends in Computer-Based Language Instruction.

    ERIC Educational Resources Information Center

    Hart, Robert S.

    1987-01-01

    A discussion of computer-based language instruction examines the quality of materials currently in use and looks at developments in the field. It is found that language courseware is generally weak in the areas of error analysis and feedback, communicative realism, and convenience of lesson authoring. A review of research under way to improve…

  6. Apollo 1 Lessons Learned Show

    NASA Image and Video Library

    2017-01-27

    Mike Ciannilli, at left, the Apollo, Challenger, Columbia Lessons Learned Program manager, presents a certificate to Charlie Duke, former Apollo 16 astronaut and member of the Apollo 1 Emergency Egress Investigation Team, during the Apollo 1 Lessons Learned presentation in the Training Auditorium at NASA's Kennedy Space Center in Florida. The program's theme was "To There and Back Again." The event helped pay tribute to the Apollo 1 crew, Gus Grissom, Ed White II, and Roger Chaffee.

  7. System safety management lessons learned from the US Army acquisition process

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Piatt, J.A.

    1989-05-01

    The Assistant Secretary of the Army for Research, Development and Acquisition directed the Army Safety Center to provide an audit of the causes of accidents and safety of use restrictions on recently fielded systems by tracking residual hazards back through the acquisition process. The objective was to develop lessons learned'' that could be applied to the acquisition process to minimize mishaps in fielded systems. System safety management lessons learned are defined as Army practices or policies, derived from past successes and failures, that are expected to be effective in eliminating or reducing specific systemic causes of residual hazards. They aremore » broadly applicable and supportive of the Army structure and acquisition objectives. Pacific Northwest Laboratory (PNL) was given the task of conducting an independent, objective appraisal of the Army's system safety program in the context of the Army materiel acquisition process by focusing on four fielded systems which are products of that process. These systems included the Apache helicopter, the Bradley Fighting Vehicle (BFV), the Tube Launched, Optically Tracked, Wire Guided (TOW) Missile and the High Mobility Multipurpose Wheeled Vehicle (HMMWV). The objective of this study was to develop system safety management lessons learned associated with the acquisition process. The first step was to identify residual hazards associated with the selected systems. Since it was impossible to track all residual hazards through the acquisition process, certain well-known, high visibility hazards were selected for detailed tracking. These residual hazards illustrate a variety of systemic problems. Systemic or process causes were identified for each residual hazard and analyzed to determine why they exist. System safety management lessons learned were developed to address related systemic causal factors. 29 refs., 5 figs.« less

  8. Homemaker/Home Health Aide.

    ERIC Educational Resources Information Center

    Missouri Univ., Columbia. Instructional Materials Lab.

    This curriculum guide provides materials for a five-unit home health aide course. Each unit contains 4 to 36 lesson plans. Unit topics and representative lesson plan topics are as follows: (1) introduction (ethical and legal responsibilities, time management, reporting and recording); (2) communication (techniques, meeting the public, therapeutic…

  9. Research Administration: Lessons Learned.

    ERIC Educational Resources Information Center

    Dummer, George H.

    1995-01-01

    The ways in which accountability issues have affected federal-university relationships, particularly in the area of academic research, are examined. Lessons university administrators have learned since issuance of Office of Management and Budget Circular A-21 in 1958, Congressional hearings on the operations of the National Institutes of Health…

  10. Lessons Learned in Building the Ares Projects

    NASA Technical Reports Server (NTRS)

    Sumrall, John Phil

    2010-01-01

    Since being established in 2005, the Ares Projects at Marshall Space Flight Center have been making steady progress designing, building, testing, and flying the next generation of exploration launch vehicles. Ares is committed to rebuilding crucial capabilities from the Apollo era that made the first human flights to the Moon possible, as well as incorporating the latest in computer technology and changes in management philosophy. One example of an Apollo-era practice has been giving NASA overall authority over vehicle integration activities, giving civil service engineers hands-on experience in developing rocket hardware. This knowledge and experience help make the agency a "smart buyer" of products and services. More modern practices have been added to the management tool belt to improve efficiency, cost effectiveness, and institutional knowledge, including knowledge management/capture to gain better insight into design and decision making; earned value management, where Ares won a NASA award for its practice and implementation; designing for operability; and Lean Six Sigma applications to identify and eliminate wasted time and effort. While it is important to learn technical lessons like how to fly and control unique rockets like the Ares I-X flight test vehicle, the Ares management team also has been learning important lessons about how to manage large, long-term projects.

  11. Writing a success story: lessons learned from the Spitzer Space Telescope

    NASA Astrophysics Data System (ADS)

    Gehrz, R. D.; Roellig, T. L.; Werner, M. W.

    2010-08-01

    A key to the success of the Spitzer Space Telescope (formerly SIRTF) Mission was a unique management structure that promoted open communication and collaboration among scientific, engineering, and contractor personnel at all levels of the project. This helped us to recruit and maintain the very best people to work on Spitzer. We describe the management concept that led to the success of the mission. Specific examples of how the project benefited from the communication and reporting structure, and lessons learned about technology are described.

  12. Accident Case Study of Organizational Silence Communication Breakdown: Shuttle Columbia, Mission STS-107

    NASA Technical Reports Server (NTRS)

    Rocha, Rodney

    2011-01-01

    This report has been developed by the National Aeronautics and Space Administration (NASA) ESMD Risk and Knowledge Management team. This document provides a point-in-time, cumulative, summary of key lessons learned derived from the official Columbia Accident Investigation Board (CAIB). Lessons learned invariably address challenges and risks and the way in which these areas have been addressed. Accordingly the risk management thread is woven throughout the document. This report is accompanied by a video that will be sent at request

  13. Supervisory Management in the Water/Wastewater Field: Self Study Program. Revised Second Edition. Textbook and Student Manual. Lessons 1-7 and Appendix. Executive Programs of the Graduate School of Business Administration of Michigan State University.

    ERIC Educational Resources Information Center

    Liebrenz, Marilyn L., Ed.

    This document is the student manual for a self-study course on managerial principles as they relate to the water or wastewater treatment field. Each of the seven lessons is concerned with a segment of the management process and corresponds to reading material in the accompanying text. An objective and subjective test portion is included in each…

  14. The failure of AHERF: 5 important lessons.

    PubMed

    Goldstein, Lisa

    2008-08-01

    Important lessons from AHERF's downfall: Strong governance and oversight of management are needed to ensure accountability; Disciplined growth strategies need to be supported by rigorous financial planning and feasibility analysis; Physician integration is critical to grow market share, but needs to be methodical and measured; Robust information systems are necessary to manage costs, maximize revenue, and provide differentiation in quality and clinical outcomes; Disclosure of the financial performance of all of a health system's operations creates greater transparency and builds credibility.

  15. Multiple statistical tests: Lessons from a d20.

    PubMed

    Madan, Christopher R

    2016-01-01

    Statistical analyses are often conducted with α= .05. When multiple statistical tests are conducted, this procedure needs to be adjusted to compensate for the otherwise inflated Type I error. In some instances in tabletop gaming, sometimes it is desired to roll a 20-sided die (or 'd20') twice and take the greater outcome. Here I draw from probability theory and the case of a d20, where the probability of obtaining any specific outcome is (1)/ 20, to determine the probability of obtaining a specific outcome (Type-I error) at least once across repeated, independent statistical tests.

  16. Government Accountability Office Bid Protests in Air Force Source Selections: Evidence and Options

    DTIC Science & Technology

    2012-01-01

    chapter, we focus on the sustained protests and lessons that can be learned from them. Th is chapter does not off er complete case histories of these...resulting research project, “Air Force Source Selections: Lessons Learned and Best Practices,” which was conducted within the Resource Management...Program of PAF in fiscal year (FY) 2009. This project studied the Air Force’s recent experience with bid protests before GAO and documented lessons that

  17. Initial impressions from the Northern California 2008 lightning siege: A report by a Wildland Fire Lessons Learned Center Information Collection Team

    Treesearch

    Jonetta T. Holt; David Christenson; Anne Black; Brett Fay; Kim Round

    2009-01-01

    This event in NorCal is another of the major events we have experienced in fire management. In line with our desire to learn, we ought to line up a team to help us capture lessons learned from this event." This statement, and a regional delegation, was the impetus for an information collection team from the Wildland Fire Lessons Learned Center to visit with...

  18. A technology ecosystem perspective on hospital management information systems: lessons from the health literature.

    PubMed

    Bain, Christopher A; Standing, Craig

    2009-01-01

    Hospital managers have a large range of information needs including quality metrics, financial reports, access information needs, educational, resourcing and decision support needs. Currently these needs involve interactions by managers with numerous disparate systems, both electronic such as SAP, Oracle Financials, PAS' (patient administration systems) like HOMER, and relevant websites; and paper-based systems. Hospital management information systems (HMIS) can be thought of sitting within a Technology Ecosystem (TE). In addition, Hospital Management Information Systems (HMIS) could benefit from a broader and deeper TE model, and the HMIS environment may in fact represents its own TE (the HMTE). This research will examine lessons from the health literature in relation to some of these issues, and propose an extension to the base model of a TE.

  19. Impact of a process improvement program in a production software environment: Are we any better?

    NASA Technical Reports Server (NTRS)

    Heller, Gerard H.; Page, Gerald T.

    1990-01-01

    For the past 15 years, Computer Sciences Corporation (CSC) has participated in a process improvement program as a member of the Software Engineering Laboratory (SEL), which is sponsored by GSFC. The benefits CSC has derived from involvement in this program are analyzed. In the environment studied, it shows that improvements were indeed achieved, as evidenced by a decrease in error rates and costs over a period in which both the size and the complexity of the developed systems increased substantially. The principles and mechanics of the process improvement program, the lessons CSC has learned, and how CSC has capitalized on these lessons are also discussed.

  20. Pitfalls in penetrating thoracic trauma (lessons we learned the hard way...).

    PubMed

    Degiannis, Elias; Zinn, Richard Joseph

    2008-10-01

    The majority of patients with penetrating thoracic trauma are managed non-operatively. Those requiring surgery usually go to theater with physiological instability. The critical condition of these patients coupled with the rarity of penetrating thoracic trauma in most European countries makes their surgical management challenging for the occasional trauma surgeon, who is usually trained as a general surgeon. Most general surgeons have a general knowledge of basic cardiothoracic operative surgery, knowledge originating from their training years and possibly enhanced by reading operative surgery textbooks. Unfortunately, the details included in most of these books are not extensive enough to provide him with enough armamentaria to tackle the difficult case. In this anatomical region, their operative dexterity and knowledge cannot be compared to that of their cardiothoracic colleagues, something that is taken for granted in their cardiothoracic trauma textbooks. Techniques that are considered basic and easy by the cardiothoracic surgeons can be unfamiliar and difficult to general surgeons. Knowing the danger points and the pitfalls that will be encountered in cardiothoracic trauma surgery will help them to avoid intraoperative errors and improve patient outcome. The purpose of this manuscript is to highlight the commonly encountered pitfalls by trauma surgeons operating on penetrating trauma to the chest.

  1. Error Analysis Of Students Working About Word Problem Of Linear Program With NEA Procedure

    NASA Astrophysics Data System (ADS)

    Santoso, D. A.; Farid, A.; Ulum, B.

    2017-06-01

    Evaluation and assessment is an important part of learning. In evaluation process of learning, written test is still commonly used. However, the tests usually do not following-up by further evaluation. The process only up to grading stage not to evaluate the process and errors which done by students. Whereas if the student has a pattern error and process error, actions taken can be more focused on the fault and why is that happen. NEA procedure provides a way for educators to evaluate student progress more comprehensively. In this study, students’ mistakes in working on some word problem about linear programming have been analyzed. As a result, mistakes are often made students exist in the modeling phase (transformation) and process skills (process skill) with the overall percentage distribution respectively 20% and 15%. According to the observations, these errors occur most commonly due to lack of precision of students in modeling and in hastiness calculation. Error analysis with students on this matter, it is expected educators can determine or use the right way to solve it in the next lesson.

  2. Intervention strategies for the management of human error

    NASA Technical Reports Server (NTRS)

    Wiener, Earl L.

    1993-01-01

    This report examines the management of human error in the cockpit. The principles probably apply as well to other applications in the aviation realm (e.g. air traffic control, dispatch, weather, etc.) as well as other high-risk systems outside of aviation (e.g. shipping, high-technology medical procedures, military operations, nuclear power production). Management of human error is distinguished from error prevention. It is a more encompassing term, which includes not only the prevention of error, but also a means of disallowing an error, once made, from adversely affecting system output. Such techniques include: traditional human factors engineering, improvement of feedback and feedforward of information from system to crew, 'error-evident' displays which make erroneous input more obvious to the crew, trapping of errors within a system, goal-sharing between humans and machines (also called 'intent-driven' systems), paperwork management, and behaviorally based approaches, including procedures, standardization, checklist design, training, cockpit resource management, etc. Fifteen guidelines for the design and implementation of intervention strategies are included.

  3. Error management in blood establishments: results of eight years of experience (2003–2010) at the Croatian Institute of Transfusion Medicine

    PubMed Central

    Vuk, Tomislav; Barišić, Marijan; Očić, Tihomir; Mihaljević, Ivanka; Šarlija, Dorotea; Jukić, Irena

    2012-01-01

    Background. Continuous and efficient error management, including procedures from error detection to their resolution and prevention, is an important part of quality management in blood establishments. At the Croatian Institute of Transfusion Medicine (CITM), error management has been systematically performed since 2003. Materials and methods. Data derived from error management at the CITM during an 8-year period (2003–2010) formed the basis of this study. Throughout the study period, errors were reported to the Department of Quality Assurance. In addition to surveys and the necessary corrective activities, errors were analysed and classified according to the Medical Event Reporting System for Transfusion Medicine (MERS-TM). Results. During the study period, a total of 2,068 errors were recorded, including 1,778 (86.0%) in blood bank activities and 290 (14.0%) in blood transfusion services. As many as 1,744 (84.3%) errors were detected before issue of the product or service. Among the 324 errors identified upon release from the CITM, 163 (50.3%) errors were detected by customers and reported as complaints. In only five cases was an error detected after blood product transfusion however without any harmful consequences for the patients. All errors were, therefore, evaluated as “near miss” and “no harm” events. Fifty-two (2.5%) errors were evaluated as high-risk events. With regards to blood bank activities, the highest proportion of errors occurred in the processes of labelling (27.1%) and blood collection (23.7%). With regards to blood transfusion services, errors related to blood product issuing prevailed (24.5%). Conclusion. This study shows that comprehensive management of errors, including near miss errors, can generate data on the functioning of transfusion services, which is a precondition for implementation of efficient corrective and preventive actions that will ensure further improvement of the quality and safety of transfusion treatment. PMID:22395352

  4. HSM implementation guide for managers.

    DOT National Transportation Integrated Search

    2011-09-01

    This guide is intended for managers of departments of transportation (DOT) charged with leading and managing agency programs impacting the project development process and safety programs. This guide is based on lessons learned from early adopters of ...

  5. Biomedical Mathematics, Unit II: Propagation of Error, Vectors and Linear Programming. Student Text. Revised Version, 1975.

    ERIC Educational Resources Information Center

    Biomedical Interdisciplinary Curriculum Project, Berkeley, CA.

    This student text presents instructional materials for a unit of mathematics within the Biomedical Interdisciplinary Curriculum Project (BICP), a two-year interdisciplinary precollege curriculum aimed at preparing high school students for entry into college and vocational programs leading to a career in the health field. Lessons concentrate on…

  6. Reflections on Pedagogy: A Journey of Collaboration

    ERIC Educational Resources Information Center

    Woods, Christine

    2011-01-01

    One of the goals of autoethnography is to "offer lessons for further conversation". In this article, the author reflects on several lessons that were learnt along a journey in management education in the area of indigenous entrepreneurship. In particular, the author outlines her pedagogical practice as an academic engaged in teaching…

  7. Energy and Transportation Lessons for the Senior High Grades.

    ERIC Educational Resources Information Center

    Parker, Francis; Yoho, Devon

    This guide presents five lessons designed to: create an awareness of the present energy situation and its relation to various aspects of transportation systems; provide knowledge of energy resources, choices, and alternative actions; develop critical thinking skills about energy and individual roles in the energy management process; encourage…

  8. Web-Based Lessons from Frontliners.

    ERIC Educational Resources Information Center

    Joseph, Linda C.

    1998-01-01

    Describes Web-site lessons and resources on the role of women in history, games, circulatory system, the study of color for emergent readers, ePals classroom exchange for French students, nutrition and the food pyramid for elementary and secondary students, and classroom management for teachers. Provides URLs for related Web sites. (PEN)

  9. Finding Possibility and Probability Lessons in Sports

    ERIC Educational Resources Information Center

    Busadee, Nutjira; Laosinchai, Parames; Panijpan, Bhinyo

    2011-01-01

    Today's students demand that their lessons be real, interesting, relevant, and manageable. Mathematics is one subject that eludes many students partly because its traditional presentation lacks those elements that encourage students to learn. Easy accessibility through electronic media has exposed people all over the world to a variety of sports…

  10. 78 FR 64202 - Meeting To Discuss Lessons Learned From Commerce Spectrum Management Advisory Committee Working...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-10-28

    ....'' \\2\\ \\2\\ Memorandum for Heads of Executive Departments and Agencies, Expanding America's Leadership in...-leadership-wireless-innovatio . Matters To Be Considered: At this meeting, NTIA will facilitate a forum for the CSMAC Working Group participants to discuss lessons learned from the collaborative efforts within...

  11. TBAL: Technology-Based Active Learning in Higher Education

    ERIC Educational Resources Information Center

    Ghilay, Yaron; Ghilay, Ruth

    2015-01-01

    In many institutions of higher education worldwide, faculty members manage lessons based on information transfer whereas their students become passive listeners. According to international research, passive learning has disadvantages mainly because students do not engage in the lesson. The study introduces a new model for higher education called…

  12. Entry Skills to Reading Using Classroom Management Strategies: A Position Statement.

    ERIC Educational Resources Information Center

    Speiss, Madeleine; Olivero, James

    The development of an entry skills behavior package designed as lessons to prepare the culturally divergent children of the Southwestern United States for beginning reading instruction in existing school programs is described. The series of 135 discrete lessons teaches auditory discrimination, associative vocabulary, listening comprehension,…

  13. Lessons learned in crisis management.

    PubMed

    Olson, Chris

    2014-01-01

    This paper will explore lessons learned following a series of natural and man-made disasters affecting the Massachusetts Mutual Life Insurance Company and/or its subsidiaries. The company employs a team of certified continuity professionals who are charged with overseeing resilience on behalf of the enterprise and leading recovery activities wherever and whenever necessary.

  14. Tools for Getting Along. What Works Clearinghouse Intervention Report

    ERIC Educational Resources Information Center

    What Works Clearinghouse, 2013

    2013-01-01

    "Tools for Getting Along" is a 26-lesson curriculum designed to help upper elementary school teachers establish a positive, cooperative classroom atmosphere. Lessons are intended to reduce disruptive and aggressive behavior by helping students develop anger management skills. Students use problem-solving steps to generate, implement, and…

  15. Lessons Learned from Military Performance Assessment.

    ERIC Educational Resources Information Center

    Wise, Lauress L.

    Lessons derived from the Job Performance Measurement (JPM) Project, which is overseen by the Office of the Assistant Secretary of Defense for Force Management and Personnel, for educational assessment are explored. The JPM Project was initiated to develop high fidelity measures of performance on the job that can be used to evaluate personnel…

  16. Lessons Learned from Accelerating Opportunity. Lessons Learned Series

    ERIC Educational Resources Information Center

    Wilson, Randall

    2015-01-01

    The Accelerating Opportunity initiative helps our nation's lowest-skilled adults earn college credentials and enter higher-wage jobs faster by combining the Adult Basic Education and career and technical training they need into one integrated curriculum. Based on four years of designing and managing Accelerating Opportunity, Jobs for the Future…

  17. USDA Forest Service watershed analyses: A lesson in interdisciplinary natural resource management

    Treesearch

    Anthony S. DeFalco

    1999-01-01

    Abstract - Recent thinking in natural resource management has led federal land management agencies such as the U.S. Department of Agriculture's Forest Service (Forest Service) to adopt ecosystem management as its official land management policy. A pivotal aspect of ecosystem management is interdisciplinary analysis of complex land management problems....

  18. Lessons from the business sector for successful knowledge management in health care: a systematic review.

    PubMed

    Kothari, Anita; Hovanec, Nina; Hastie, Robyn; Sibbald, Shannon

    2011-07-25

    The concept of knowledge management has been prevalent in the business sector for decades. Only recently has knowledge management been receiving attention by the health care sector, in part due to the ever growing amount of information that health care practitioners must handle. It has become essential to develop a way to manage the information coming in to and going out of a health care organization. The purpose of this paper was to summarize previous studies from the business literature that explored specific knowledge management tools, with the aim of extracting lessons that could be applied in the health domain. We searched seven databases using keywords such as "knowledge management", "organizational knowledge", and "business performance". We included articles published between 2000-2009; we excluded non-English articles. 83 articles were reviewed and data were extracted to: (1) uncover reasons for initiating knowledge management strategies, (2) identify potential knowledge management strategies/solutions, and (3) describe facilitators and barriers to knowledge management. KM strategies include such things as training sessions, communication technologies, process mapping and communities of practice. Common facilitators and barriers to implementing these strategies are discussed in the business literature, but rigorous studies about the effectiveness of such initiatives are lacking. The health care sector is at a pinnacle place, with incredible opportunities to design, implement (and evaluate) knowledge management systems. While more research needs to be done on how best to do this in healthcare, the lessons learned from the business sector can provide a foundation on which to build.

  19. Lessons from the business sector for successful knowledge management in health care: A systematic review

    PubMed Central

    2011-01-01

    Background The concept of knowledge management has been prevalent in the business sector for decades. Only recently has knowledge management been receiving attention by the health care sector, in part due to the ever growing amount of information that health care practitioners must handle. It has become essential to develop a way to manage the information coming in to and going out of a health care organization. The purpose of this paper was to summarize previous studies from the business literature that explored specific knowledge management tools, with the aim of extracting lessons that could be applied in the health domain. Methods We searched seven databases using keywords such as "knowledge management", "organizational knowledge", and "business performance". We included articles published between 2000-2009; we excluded non-English articles. Results 83 articles were reviewed and data were extracted to: (1) uncover reasons for initiating knowledge management strategies, (2) identify potential knowledge management strategies/solutions, and (3) describe facilitators and barriers to knowledge management. Conclusions KM strategies include such things as training sessions, communication technologies, process mapping and communities of practice. Common facilitators and barriers to implementing these strategies are discussed in the business literature, but rigorous studies about the effectiveness of such initiatives are lacking. The health care sector is at a pinnacle place, with incredible opportunities to design, implement (and evaluate) knowledge management systems. While more research needs to be done on how best to do this in healthcare, the lessons learned from the business sector can provide a foundation on which to build. PMID:21787403

  20. Getting started in business: from fantasy to reality.

    PubMed

    Finnigan, S

    1996-01-01

    Numerous theories and concepts of business management are available in the authoriatative literature. Some of the important lessons for getting started in business, and more important, staying in business may not, however, be found there. The practical business realities that influence success are the real-life lessons. They include examining worthwhile motives, applying commonsense approaches, demonstrating value to the customer, and achieving early and sustained profitability. Such lessons and other principles of entrepreneurship must be learned to create a successful beginning and long-term business viability.

  1. Space Shuttle Reusable Solid Rocket Motor Program Overview and Lessons Learned

    NASA Technical Reports Server (NTRS)

    Graves, Stan R.; McCool, Alex (Technical Monitor)

    2001-01-01

    An overview of the Space Shuttle Reusable Solid Rocket Motor (RSRM) program is provided with a summary of lessons learned since the first test firing in 1977. Fifteen different lessons learned are discussed that fundamentally changed the motor's design, processing, and RSRM program risk management systems. The evolution of the rocket motor design is presented including the baseline or High Performance Solid Rocket Motor (HPM), the Filament Wound Case (FWC), the RSRM, and the proposed Five-Segment Booster (FSB).

  2. Lessons Learned from the First Decade of Adaptive Management in Comprehensive Everglades Restoration

    EPA Science Inventory

    Although few successful examples of large-scale adaptive management applications are available to ecosystem restoration scientists and managers, examining where and how the components of an adaptive management program have been successfully implemented yields insight into what ...

  3. Communicating Ecological Data with Land Managers: Lessons Learned

    USDA-ARS?s Scientific Manuscript database

    Communicating ecological data to land managers and management entities represents a different challenge than communicating with the general public. Land managers need to not only understand results but also the inherent limits and assumptions in order to make effective and legally defensible decisio...

  4. Considerations for implementing an organizational lessons learned process.

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Fosshage, Erik D

    2013-05-01

    This report examines the lessons learned process by a review of the literature in a variety of disciplines, and is intended as a guidepost for organizations that are considering the implementation of their own closed-loop learning process. Lessons learned definitions are provided within the broader context of knowledge management and the framework of a learning organization. Shortcomings of existing practices are summarized in an attempt to identify common pitfalls that can be avoided by organizations with fledgling experiences of their own. Lessons learned are then examined through a dual construct of both process and mechanism, with emphasis on integrating intomore » organizational processes and promoting lesson reuse through data attributes that contribute toward changed behaviors. The report concludes with recommended steps for follow-on efforts.« less

  5. Towards a Framework for Managing Risk Associated with Technology-Induced Error.

    PubMed

    Borycki, Elizabeth M; Kushniruk, Andre W

    2017-01-01

    Health information technologies (HIT) promised to streamline and modernize healthcare processes. However, a growing body of research has indicated that if such technologies are not designed, implemented or maintained properly this may lead to an increased incidence of new types of errors which the authors have referred to as "technology-induced errors". In this paper, framework is presented that can be used to manage HIT risk. The framework considers the reduction of technology-induced errors at different stages by managing risks associated with the implementation of HIT. Frameworks that allow health information technology managers to employ proactive and preventative approaches that can be used to manage the risks associated with technology-induced errors are critical to improving HIT safety and managing risk associated with implementing new technologies.

  6. Patients' views of receiving lessons in the Alexander technique and an exercise prescription for managing back pain in the ATEAM trial.

    PubMed

    Yardley, Lucy; Dennison, Laura; Coker, Rebecca; Webley, Frances; Middleton, Karen; Barnett, Jane; Beattie, Angela; Evans, Maggie; Smith, Peter; Little, Paul

    2010-04-01

    Lessons in the Alexander Technique and exercise prescription proved effective for managing low back pain in primary care in a clinical trial. To understand trial participants' expectations and experiences of the Alexander Technique and exercise prescription. A questionnaire assessing attitudes to the intervention, based on the Theory of Planned Behaviour, was completed at baseline and 3-month follow-up by 183 people assigned to lessons in the Alexander Technique and 176 people assigned to exercise prescription. Semi-structured interviews to assess the beliefs contributing to attitudes to the intervention were carried out at baseline with14 people assigned to the lessons in the Alexander Technique and 16 to exercise prescription, and at follow-up with 15 members of the baseline sample. Questionnaire responses indicated that attitudes to both interventions were positive at baseline but became more positive at follow-up only in those assigned to lessons in the Alexander Technique. Thematic analysis of the interviews suggested that at follow-up many patients who had learned the Alexander Technique felt they could manage back pain better. Whereas many obstacles to exercising were reported, few barriers to learning the Alexander Technique were described, since it 'made sense', could be practiced while carrying out everyday activities or relaxing, and the teachers provided personal advice and support. Using the Alexander Technique was viewed as effective by most patients. Acceptability may have been superior to exercise because of a convincing rationale and social support and a better perceived fit with the patient's particular symptoms and lifestyle.

  7. Lessons Learned from Client Projects in an Undergraduate Project Management Course

    ERIC Educational Resources Information Center

    Pollard, Carol E.

    2012-01-01

    This work proposes that a subtle combination of three learning methods offering "just in time" project management knowledge, coupled with hands-on project management experience can be particularly effective in producing project management students with employable skills. Students were required to apply formal project management knowledge to gain…

  8. Lessons from Australian Water Reform for the Colorado River Basin (Invited)

    NASA Astrophysics Data System (ADS)

    Udall, B.

    2010-12-01

    The Murray Darling Basin in Australia (MDB) and the Colorado River Basin (CRB) share many geographical, climatic, and legal similarities. Both are predominantly arid, approximately the same size, occupy similar latitudes, have major snowmelt tributaries as well as very arid tributaries, were allocated by interstate agreements early in the 20th century, have multi-year carryover storage, are threatened by mid-latitude climate change related drying, and during the last ten years have suffered under droughts of historic proportions. Some management practices have begun to change in the CRB, e.g. the multi-state 2007 shortage-sharing agreement, but in the MDB significant water management reform began in 1994 and has accelerated during the recent drought. The Australian language around water, conservation ethic, national and state policies, infrastructure, especially desalination, and even water management entities have undergone substantial changes during the last five years. Australia’s new National Water Commission, set up specifically to oversee reform, is on the verge of releasing a new basin management plan which will govern MDB management over the next decade. Which of these many reform-related lessons from Australia might be applicable to the Colorado River Basin and why? And which of the lessons might not be applicable and why?

  9. Exploring Senior Residents' Intraoperative Error Management Strategies: A Potential Measure of Performance Improvement.

    PubMed

    Law, Katherine E; Ray, Rebecca D; D'Angelo, Anne-Lise D; Cohen, Elaine R; DiMarco, Shannon M; Linsmeier, Elyse; Wiegmann, Douglas A; Pugh, Carla M

    The study aim was to determine whether residents' error management strategies changed across 2 simulated laparoscopic ventral hernia (LVH) repair procedures after receiving feedback on their initial performance. We hypothesize that error detection and recovery strategies would improve during the second procedure without hands-on practice. Retrospective review of participant procedural performances of simulated laparoscopic ventral herniorrhaphy. A total of 3 investigators reviewed procedure videos to identify surgical errors. Errors were deconstructed. Error management events were noted, including error identification and recovery. Residents performed the simulated LVH procedures during a course on advanced laparoscopy. Participants had 30 minutes to complete a LVH procedure. After verbal and simulator feedback, residents returned 24 hours later to perform a different, more difficult simulated LVH repair. Senior (N = 7; postgraduate year 4-5) residents in attendance at the course participated in this study. In the first LVH procedure, residents committed 121 errors (M = 17.14, standard deviation = 4.38). Although the number of errors increased to 146 (M = 20.86, standard deviation = 6.15) during the second procedure, residents progressed further in the second procedure. There was no significant difference in the number of errors committed for both procedures, but errors shifted to the late stage of the second procedure. Residents changed the error types that they attempted to recover (χ 2 5 =24.96, p<0.001). For the second procedure, recovery attempts increased for action and procedure errors, but decreased for strategy errors. Residents also recovered the most errors in the late stage of the second procedure (p < 0.001). Residents' error management strategies changed between procedures following verbal feedback on their initial performance and feedback from the simulator. Errors and recovery attempts shifted to later steps during the second procedure. This may reflect residents' error management success in the earlier stages, which allowed further progression in the second simulation. Incorporating error recognition and management opportunities into surgical training could help track residents' learning curve and provide detailed, structured feedback on technical and decision-making skills. Copyright © 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

  10. It`s slim with a plain green cover: Australia`s management plan for polychlorinated biphenyls

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Brotherton, P.D.

    1996-12-31

    In November 1995, the Australian and New Zealand Environment and Conservation Council (ANZECC, the Council of State and National Environment Ministers) adopted a National Management Plan for PCBs. This was a significant milestone in the very long saga of Australian efforts to develop public policy and management structures for dealing with persistent organochlorine wastes. The author was part of a four-person consultation panel that carried out a public involvement program to assist and inform the process of developing the National Management Plan. The program involved, among other things, visiting every state and territory of Australia at least twice. This papermore » describes the development and delivery of the public involvement program, including ongoing interactions with Governments. The latter is often a complex (and many would say an unduly complex) matter in the federal system, where primary responsibility for waste management resides in the individual state/territory jurisdictions. The paper also attempts to draw lessons from the process. While some participants learned and acted upon some of these lessons quite early in the process, other participants (particularly governments) took longer to realize their importance and thus took longer to refrain from actions that might be regarded as not keeping faith with the activities they had set in process. Finally, the lessons learned here are contrasted with those drawn by participants in the process that led to the establishment and expansion of the Swan Hills facility in Alberta. While the outcomes of the Australian and Albertan processes appear to be very different, a number of the essential lessons to be drawn from the two processes are virtually identical. 13 refs.« less

  11. The Value of Identifying and Recovering Lost GN&C Lessons Learned: Aeronautical, Spacecraft, and Launch Vehicle Examples

    NASA Technical Reports Server (NTRS)

    Dennehy, Cornelius J.; Labbe, Steve; Lebsock, Kenneth L.

    2010-01-01

    Within the broad aerospace community the importance of identifying, documenting and widely sharing lessons learned during system development, flight test, operational or research programs/projects is broadly acknowledged. Documenting and sharing lessons learned helps managers and engineers to minimize project risk and improve performance of their systems. Often significant lessons learned on a project fail to get captured even though they are well known 'tribal knowledge' amongst the project team members. The physical act of actually writing down and documenting these lessons learned for the next generation of NASA GN&C engineers fails to happen on some projects for various reasons. In this paper we will first review the importance of capturing lessons learned and then will discuss reasons why some lessons are not documented. A simple proven approach called 'Pause and Learn' will be highlighted as a proven low-impact method of organizational learning that could foster the timely capture of critical lessons learned. Lastly some examples of 'lost' GN&C lessons learned from the aeronautics, spacecraft and launch vehicle domains are briefly highlighted. In the context of this paper 'lost' refers to lessons that have not achieved broad visibility within the NASA-wide GN&C CoP because they are either undocumented, masked or poorly documented in the NASA Lessons Learned Information System (LLIS).

  12. The Network Operations Control Center upgrade task: Lessons learned

    NASA Technical Reports Server (NTRS)

    Sherif, J. S.; Tran, T.-L.; Lee, S.

    1994-01-01

    This article synthesizes and describes the lessons learned from the Network Operations Control Center (NOCC) upgrade project, from the requirements phase through development and test and transfer. At the outset, the NOCC upgrade was being performed simultaneously with two other interfacing and dependent upgrades at the Signal Processing Center (SPC) and Ground Communications Facility (GCF), thereby adding a significant measure of complexity to the management and overall coordination of the development and transfer-to-operations (DTO) effort. Like other success stories, this project carried with it the traditional elements of top management support and exceptional dedication of cognizant personnel. Additionally, there were several NOCC-specific reasons for success, such as end-to-end system engineering, adoption of open-system architecture, thorough requirements management, and use of appropriate off-the-shelf technologies. On the other hand, there were several difficulties, such as ill-defined external interfaces, transition issues caused by new communications protocols, ambivalent use of two sets of policies and standards, and mistailoring of the new JPL management standard (due to the lack of practical guidelines). This article highlights the key lessons learned, as a means of constructive suggestions for the benefit of future projects.

  13. Policy experimentation and innovation as a response to complexity in China's management of health reforms.

    PubMed

    Husain, Lewis

    2017-08-03

    There are increasing criticisms of dominant models for scaling up health systems in developing countries and a recognition that approaches are needed that better take into account the complexity of health interventions. Since Reform and Opening in the late 1970s, Chinese government has managed complex, rapid and intersecting reforms across many policy areas. As with reforms in other policy areas, reform of the health system has been through a process of trial and error. There is increasing understanding of the importance of policy experimentation and innovation in many of China's reforms; this article argues that these processes have been important in rebuilding China's health system. While China's current system still has many problems, progress is being made in developing a functioning system able to ensure broad population access. The article analyses Chinese thinking on policy experimentation and innovation and their use in management of complex reforms. It argues that China's management of reform allows space for policy tailoring and innovation by sub-national governments under a broad agreement over the ends of reform, and that shared understandings of policy innovation, alongside informational infrastructures for the systemic propagation and codification of useful practices, provide a framework for managing change in complex environments and under conditions of uncertainty in which 'what works' is not knowable in advance. The article situates China's use of experimentation and innovation in management of health system reform in relation to recent literature which applies complex systems thinking to global health, and concludes that there are lessons to be learnt from China's approaches to managing complexity in development of health systems for the benefit of the poor.

  14. The Oklahoma bombing. Lessons learned.

    PubMed

    Anteau, C M; Williams, L A

    1997-06-01

    The Oklahoma City bombing experience in April of 1995 provided a unique opportunity to test the effectiveness of an existing disaster plan. The critical care nurses at Columbia Presbyterian Hospital learned valuable lessons about managing intense activity, equipment and supplies, staffing resources, and visitor issues. The degree to which the bombing affected the emotional state of personnel was unanticipated, and leaders learned that critical stress management interventions should be included in every emergency preparedness plan. Additionally, recommendations include using runners for communication; assigning specific roles (supplies, staffing, triage); keeping additional staff in reserve for shift relief; ensuring ample hospital staff members are available to coordinate visitors and media; and setting up record systems to preserve continuity. The unique lessons learned as a result of this terrorist attack can be used by other critical care nurses to understand and refine disaster plans.

  15. Implementation of a commercial-grade dedication program - Benefits and lessons learned

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Harrington, M.; MacFarlane, I.

    1991-01-01

    The recent issuance of industry guidelines, the Nuclear Management and Resources Council procurement initiative, and a US Nuclear Regulatory Commission NRC generic letter on commercial-grade item dedication (CGD) has been viewed by many utility managers and executives as only adding to the existing burden of compliance with regulatory requirements. While the incorporation of these documents into existing CGD programs has created additional costs, the resulting enhanced dedication programs have also produced benefits beyond regulatory compliance, and some lessons have been learned. This paper discusses the benefits and the lessons learned during implementation of an enhanced CGD program at New Hampshiremore » Yankee's (NHY's) Seabrook nuclear plant. Based on NHY's experience, it is believed that the benefits described in this paper can be realized by other utilities implementing CGD programs.« less

  16. Online survey software as a data collection tool for medical education: A case study on lesson plan assessment.

    PubMed

    Kimiafar, Khalil; Sarbaz, Masoumeh; Sheikhtaheri, Abbas

    2016-01-01

    Background: There are no general strategies or tools to evaluate daily lesson plans; however, assessments conducted using traditional methods usually include course plans. This study aimed to evaluate the strengths and weaknesses of online survey software in collecting data on education in medical fields and the application of such softwares to evaluate students' views and modification of lesson plans. Methods: After investigating the available online survey software, esurveypro was selected for assessing daily lesson plans. After using the software for one semester, a questionnaire was prepared to assess the advantages and disadvantages of this method and students' views in a cross-sectional study. Results: The majority of the students (51.7%) rated the evaluation of classes per session (lesson plans) using the online survey as useful or very useful. About 51% (n=36) of the students considered this method effective in improving the management of each session, 67.1% (n=47) considered it effective in improving the management of sessions for the next semester, and 51.4% (n=36) said it had a high impact on improving the educational content of subsequent sessions. Finally, 61.4% (n=43) students expressed high and very high levels of satisfaction with using an online survey at each session. Conclusion: The use of online surveys may be appropriate to improve lesson plans and educational planning at different levels. This method can be used for other evaluations and for assessing people's opinions at different levels of an educational system.

  17. Cancer Care Ontario and integrated cancer programs: portrait of a performance management system and lessons learned.

    PubMed

    Cheng, Siu Mee; Thompson, Leslee J

    2006-01-01

    A performance management system has been implemented by Cancer Care Ontario (CCO). This system allows for the monitoring and management of 11 integrated cancer programs (ICPs) across the Province of Ontario. The system comprises of four elements: reporting frequency, reporting requirements, review meetings and accountability and continuous improvement activities. CCO and the ICPs have recently completed quarterly performance review exercises for the last two quarters of the fiscal year 2004-2005. The purpose of this paper is to address some of the key lessons learned. The paper provides an outline of the CCO performance management system. These lessons included: data must be valid and reliable; performance management requires commitments from both parties in the performance review exercises; streamlining performance reporting is beneficial; technology infrastructure which allows for cohesive management of data is vital for a sustainable performance management system; performance indicators need to stand up to scrutiny by both parties; and providing comparative data across the province is valuable. Critical success factors which would help to ensure a successful performance management system include: corporate engagement from various parts of an organization in the review exercises; desire to focus on performance improvement and avoidance of blaming; and strong data management systems. The performance management system is a practical and sustainable system that allows for performance improvement of cancer care services. It can be a vital tool to enhance accountability within the health care system. The paper demonstrates that the performance management system supports accountability in the cancer care system for Ontario, and reflects the principles of the provincial governments commitment to continuous improvement of healthcare.

  18. Lessons Learned from the Everglades Collaborative Adaptive Management Program

    EPA Science Inventory

    Recent technical papers explore whether adaptive management (AM) is useful for environmental management and restoration efforts and discuss the many challenges to overcome for successful implementation, especially for large-scale restoration programs (McLain and Lee 1996; Levine ...

  19. Introduction to Animal Nutrition. Instructor Guide [and] Student Reference. Volume 28, Number 7 [and] Volume 28, Number 8.

    ERIC Educational Resources Information Center

    Peiter, Andrea; And Others

    This instructor guide and the corresponding student reference contain five lessons about animal science for inclusion in Vocational Instructional Management System (VIMS) agricultural education courses. The lessons cover these topics: the monogastric digestive system, the ruminant digestive system, the importance of meeting nutritional needs, how…

  20. The Candy Store Lesson: Sweetening the Integration of Subject Areas.

    ERIC Educational Resources Information Center

    Wiest, Lynda R.; Morris, Darryl L.

    1998-01-01

    Provides a lesson that integrates economics, mathematics, history, and language arts through a common interest of all elementary students: candy. Explains that the students managed and shopped at three classroom candy stores while learning economics concepts, such as supply and demand and the relationship of price to buying decisions. (CMK)

  1. 76 FR 3878 - Mid-Atlantic Fishery Management Council; Public Meetings

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-01-21

    ... Lessons Learned from the Transition to Sectors. 2:30 p.m. until 3:30 p.m.--The Shad/River Herring... convene to hear a presentation provided by Gulf of Maine Research Institute regarding the Lessons Learned... action on SSC member nominations. Although non-emergency issues not contained in this agenda may come...

  2. Eco-Schools Scotland: Lessons Learned from First-Hand Experience

    ERIC Educational Resources Information Center

    Fraser, Neil

    2010-01-01

    Secondary schools are tasked with becoming sustainable institutions but this can be difficult to achieve because of a lack of time, shortage of project ideas and limited environmental management expertise. The Eco-Schools initiative exists to overcome these issues, and lessons learned from some schools in Scotland can help other schools implement…

  3. Asthma Education: An Integrated Approach. Ideas for Elementary Classrooms.

    ERIC Educational Resources Information Center

    Minnesota State Dept. of Health, St. Paul.

    This manual contains lesson plans for teaching all children how to monitor their own health and for teaching children with asthma how to play a role in the management of their condition. Each lesson plan is compatible with existing traditional elementary curricula for math, science, health, or language arts. After an introduction that discusses…

  4. Basic Training Course/Emergency Medical Technician (Second Edition). Instructor's Lesson Plan.

    ERIC Educational Resources Information Center

    National Highway Traffic Safety Administration (DOT), Washington, DC.

    This document containing instructor lesson plans is one of three prepared to update a basic training program for emergency medical technicians (EMTs). (A course guide containing planning and management information and a study guide are available separately.) Material covers all emergency medical techniques currently considered to be within the…

  5. Games Teachers and Students Play: An Analysis of Motivation in Three Fifth Grade Classrooms.

    ERIC Educational Resources Information Center

    Marshall, Hermine H.

    Motivational strategies and attitudes toward learning were examined among students in three fifth-grade classrooms. Teacher statements used to frame lessons, maintain the session and keep students on task, and handle responsibility for learning were extracted from transcripts of classroom observations. Lesson framing and management/maintenance…

  6. Multiscale socioeconomic assessment across large ecosystems: lessons from practice

    Treesearch

    Rebecca J. McLain; Ellen M. Donoghue; Jonathan Kusel; Lita Buttolph; Susan Charnley

    2008-01-01

    Implementation of ecosystem management projects has created a demand for socioeconomic assessments to predict or evaluate the impacts of ecosystem policies. Social scientists for these assessments face challenges that, although not unique to such projects, are more likely to arise than in smaller scale ones. This article summarizes lessons from our experiences with...

  7. Hey, We See It Differently! Lessons on Team Dynamics.

    ERIC Educational Resources Information Center

    Walz, Lynn; Vandercook, Terri; Medwetz, Laura; Nelson, Marilyn; Thurlow, Martha

    This monograph summarizes lessons learned from the 5 years that the Together We're Better (TWB) program worked to create inclusive learning environments in four Minnesota school districts. Each of the partner districts established a collaborative core planning team to provide leadership and management of efforts toward school change and inclusive…

  8. Conflicts in Science the Classroom: Documentation and Management through Phenomenological Methodology

    ERIC Educational Resources Information Center

    Oloruntegbe, K. O.; Omoniyi, A. O.; Omoniyi, M. B. I.; Ojelade, I. A.

    2011-01-01

    The study investigated the nature of conflicts that are generated in the science classroom. Twenty video-recorded lessons taught by 10 randomly selected pre-service science teachers in teaching practice in a few Nigerian secondary schools were analyzed. Beside the expected goal attainment of the lessons a number of negative conflicts were…

  9. Evaluating the Effective Factors for Reporting Medical Errors among Midwives Working at Teaching Hospitals Affiliated to Isfahan University of Medical Sciences.

    PubMed

    Khorasani, Fahimeh; Beigi, Marjan

    2017-01-01

    Recently, evaluation and accreditation system of hospitals has had a special emphasis on reporting malpractices and sharing errors or lessons learnt from errors, but still due to lack of promotion of systematic approach for solving problems from the same system, this issue has remained unattended. This study was conducted to determine the effective factors for reporting medical errors among midwives. This project was a descriptive cross-sectional observational study. Data gathering tools were a standard checklist and two researcher-made questionnaires. Sampling for this study was conducted from all the midwives who worked at teaching hospitals affiliated to Isfahan University of Medical Sciences through census method (convenient) and lasted for 3 months. Data were analyzed using descriptive and inferential statistics through SPSS 16. Results showed that 79.1% of the staff reported errors and the highest rate of errors was in the process of patients' tests. In this study, the mean score of midwives' knowledge about the errors was 79.1 and the mean score of their attitude toward reporting errors was 70.4. There was a direct relation between the score of errors' knowledge and attitude in the midwifery staff and reporting errors. Based on the results of this study about the appropriate knowledge and attitude of midwifery staff regarding errors and action toward reporting them, it is recommended to strengthen the system when it comes to errors and hospitals risks.

  10. [Malpractice in Urology: lessons of clinical and legal safety.

    PubMed

    Vargas-Blasco, César; Gómez-Durán, Esperanza L; Martin-Fumadó, Carles; Arimany-Manso, Josep

    2018-06-01

    Data about urology malpractice claims in our environment are scarce and should be considered a potential opportunity to "learn from errors". We analyzed every claim for alleged malpractice in Urology managed by the Council of Medical Colleges of Catalonia between 1990 and 2012, and specifically evaluated the clinical and medicolegal features of those cases with medical professional responsibility. We identified 182 cases in 22 years, but only the 25,74%showed professional liability. Testicular torsion misdiagnosis, pregnancies after vasectomy and complications of lithiasis should be noted for their frequency of claims and rate of liability. 246 physicians were involved, 89% were males and mean age was 45.6 years. Most cases (n=137, 75.27%) were processed in the courts. Urology has a medium risk of claims, with a moderate rate of medical professional liability and amount of compensation. There are specific actions that would lead to clinical safety improvements, particularly in testicular pathologies, vasectomy and lithiasis. Finally, more attention should be paid to proper patient information.

  11. A shared electronic health record: lessons from the coalface.

    PubMed

    Silvester, Brett V; Carr, Simon J

    2009-06-01

    A shared electronic health record system has been successfully implemented in Australia by a Division of General Practice in northern Brisbane. The system grew out of coordinated care trials that showed the critical need to share summary patient information, particularly for patients with complex conditions who require the services of a wide range of multisector, multidisciplinary health care professionals. As at 30 April 2008, connected users of the system included 239 GPs from 66 general practices, two major public hospitals, three large private hospitals, 11 allied health and community-based provider organisations and 1108 registered patients. Access data showed a patient's shared record was accessed an average of 15 times over a 12-month period. The success of the Brisbane implementation relied on seven key factors: connectivity, interoperability, change management, clinical leadership, targeted patient involvement, information at the point of care, and governance. The Australian Commission on Safety and Quality in Health Care is currently evaluating the system for its potential to reduce errors relating to inadequate information transfer during clinical handover.

  12. Lessons about Virtual-Environment Software Systems from 20 years of VE building

    PubMed Central

    Taylor, Russell M.; Jerald, Jason; VanderKnyff, Chris; Wendt, Jeremy; Borland, David; Marshburn, David; Sherman, William R.; Whitton, Mary C.

    2010-01-01

    What are desirable and undesirable features of virtual-environment (VE) software architectures? What should be present (and absent) from such systems if they are to be optimally useful? How should they be structured? To help answer these questions we present experience from application designers, toolkit designers, and VE system architects along with examples of useful features from existing systems. Topics are organized under the major headings of: 3D space management, supporting display hardware, interaction, event management, time management, computation, portability, and the observation that less can be better. Lessons learned are presented as discussion of the issues, field experiences, nuggets of knowledge, and case studies. PMID:20567602

  13. Selecting a Laboratory Information Management System for Biorepositories in Low- and Middle-Income Countries: The H3Africa Experience and Lessons Learned

    PubMed Central

    Musinguzi, Henry; Lwanga, Newton; Kezimbira, Dafala; Kigozi, Edgar; Katabazi, Fred Ashaba; Wayengera, Misaki; Joloba, Moses Lutaakome; Abayomi, Emmanuel Akin; Swanepoel, Carmen; Croxton, Talishiea; Ozumba, Petronilla; Thankgod, Anazodo; van Zyl, Lizelle; Mayne, Elizabeth Sarah; Kader, Mukthar; Swartz, Garth

    2017-01-01

    Biorepositories in Africa need significant infrastructural support to meet International Society for Biological and Environmental Repositories (ISBER) Best Practices to support population-based genomics research. ISBER recommends a biorepository information management system which can manage workflows from biospecimen receipt to distribution. The H3Africa Initiative set out to develop regional African biorepositories where Uganda, Nigeria, and South Africa were successfully awarded grants to develop the state-of-the-art biorepositories. The biorepositories carried out an elaborate process to evaluate and choose a laboratory information management system (LIMS) with the aim of integrating the three geographically distinct sites. In this article, we review the processes, African experience, lessons learned, and make recommendations for choosing a biorepository LIMS in the African context.

  14. Lessons learned and their application to program development and cultural issues

    NASA Technical Reports Server (NTRS)

    Roth, Gilbert L.

    1991-01-01

    The main objectives of space product assurance are, in effect, the same as those of Total Quality Management (TQM) or its many variants. The most significant ingredients are the lessons learned and their application to ongoing and future programs as they are affected by changes in the cultural environment. The cultural issues which affect almost everything done in technical programs and projects are considered. Understanding the lessons learned and the synergism which results from this combination of knowledge, culture, and lessons learned is identified as crucial. A brief discussion of the closed loop linkage that should exist between the world of hands on activities and that of educational institutions is presented.

  15. Lessons Learned for Improving Spacecraft Ground Operations

    NASA Technical Reports Server (NTRS)

    Bell, Michael; Henderson, Gena; Stambolian, Damon

    2013-01-01

    NASA policy requires each Program or Project to develop a plan for how they will address Lessons Learned. Projects have the flexibility to determine how best to promote and implement lessons learned. A large project might budget for a lessons learned position to coordinate elicitation, documentation and archival of the project lessons. The lessons learned process crosses all NASA Centers and includes the contactor community. o The Office of The Chief Engineer at NASA Headquarters in Washington D.C., is the overall process owner, and field locations manage the local implementation. One tool used to transfer knowledge between program and projects is the Lessons Learned Information System (LLIS). Most lessons come from NASA in partnership with support contractors. A search for lessons that might impact a new design is often performed by a contractor team member. Knowledge is not found with only one person, one project team, or one organization. Sometimes, another project team, or person, knows something that can help your project or your task. Knowledge sharing is an everyday activity at the Kennedy Space Center through storytelling, Kennedy Engineering Academy presentations and through searching the Lessons Learned Information system. o Project teams search the lessons repository to ensure the best possible results are delivered. o The ideas from the past are not always directly applicable but usually spark new ideas and innovations. Teams have a great responsibility to collect and disseminate these lessons so that they are shared with future generations of space systems designers. o Leaders should set a goal for themselves to host a set numbers of lesson learned events each year and do more to promote multiple methods of lessons learned activities. o High performing employees are expected to share their lessons, however formal knowledge sharing presentation are not the norm for many employees.

  16. Factors associated with reporting of medication errors by Israeli nurses.

    PubMed

    Kagan, Ilya; Barnoy, Sivia

    2008-01-01

    This study investigated medication error reporting among Israeli nurses, the relationship between nurses' personal views about error reporting, and the impact of the safety culture of the ward and hospital on this reporting. Nurses (n = 201) completed a questionnaire related to different aspects of error reporting (frequency, organizational norms of dealing with errors, and personal views on reporting). The higher the error frequency, the more errors went unreported. If the ward nurse manager corrected errors on the ward, error self-reporting decreased significantly. Ward nurse managers have to provide good role models.

  17. Applying EVM to Satellite on Ground and In-Orbit Testing - Better Data in Less Time

    NASA Technical Reports Server (NTRS)

    Peters, Robert; Lebbink, Elizabeth-Klein; Lee, Victor; Model, Josh; Wezalis, Robert; Taylor, John

    2008-01-01

    Using Error Vector Magnitude (EVM) in satellite integration and test allows rapid verification of the Bit Error Rate (BER) performance of a satellite link and is particularly well suited to measurement of low bit rate satellite links where it can result in a major reduction in test time (about 3 weeks per satellite for the Geosynchronous Operational Environmental Satellite [GOES] satellites during ground test) and can provide diagnostic information. Empirical techniques developed to predict BER performance from EVM measurements and lessons learned about applying these techniques during GOES N, O, and P integration test and post launch testing, are discussed.

  18. Lessons about Cash and Manager Priorities

    ERIC Educational Resources Information Center

    Mong, Donald

    2013-01-01

    Experienced managers know that cash affects virtually every aspect of a company's strategy and operations. Business students and new managers, however, sometimes lose sight of the importance of cash amidst the details of accrual-based accounting courses, formula-based finance courses, and production-based management courses. We therefore use…

  19. 77 FR 41457 - Aging Management Associated With Wall Thinning Due to Erosion Mechanisms

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-07-13

    ... NUCLEAR REGULATORY COMMISSION [NRC-2012-0170] Aging Management Associated With Wall Thinning Due... management program (AMP) in NUREG-1801, Revision 2, ``Generic Aging Lessons Learned (GALL) Report,'' and the NRC staff's aging management review procedure and acceptance criteria contained in NUREG-1800...

  20. Tubing misconnections--a systems failure with human factors: lessons for nursing practice.

    PubMed

    Simmons, Debora; Graves, Krisanne

    2008-12-01

    In a neonatal unit, an experienced nurse inadvertently connected a feeding tube to an intravenous catheter. An analysis of this error, including the historical perspective, reveals that this threat to safety has been documented since 1972. Implications for nursing practice include the redesign of systems to accommodate human factors science and a change in health care's view of vigilance.

  1. Lessons Learned for Collaborative Clinical Content Development

    PubMed Central

    Collins, S.A.; Bavuso, K.; Zuccotti, G.; Rocha, R.A.

    2013-01-01

    Background Site-specific content configuration of vendor-based Electronic Health Records (EHRs) is a vital step in the development of standardized and interoperable content that can be used for clinical decision-support, reporting, care coordination, and information exchange. The multi-site, multi-stakeholder Acute Care Documentation (ACD) project at Partners Healthcare Systems (PHS) aimed to develop highly structured clinical content with adequate breadth and depth to meet the needs of all types of acute care clinicians at two academic medical centers. The Knowledge Management (KM) team at PHS led the informatics and knowledge management effort for the project. Objectives We aimed to evaluate the role, governance, and project management processes and resources for the KM team’s effort as part of the standardized clinical content creation. Methods We employed the Center for Disease Control’s six step Program Evaluation Framework to guide our evaluation steps. We administered a forty-four question, open-ended, semi-structured voluntary survey to gather focused, credible evidence from members of the KM team. Qualitative open-coding was performed to identify themes for lessons learned and concluding recommendations. Results Six surveys were completed. Qualitative data analysis informed five lessons learned and thirty specific recommendations associated with the lessons learned. The five lessons learned are: 1) Assess and meet knowledge needs and set expectations at the start of the project; 2) Define an accountable decision-making process; 3) Increase team meeting moderation skills; 4) Ensure adequate resources and competency training with online asynchronous collaboration tools; 5) Develop focused, goal-oriented teams and supportive, consultative service based teams. Conclusions Knowledge management requirements for the development of standardized clinical content within a vendor-based EHR among multi-stakeholder teams and sites include: 1) assessing and meeting informatics knowledge needs, 2) setting expectations and standardizing the process for decision-making, and 3) ensuring the availability of adequate resources and competency training. PMID:23874366

  2. Processor register error correction management

    DOEpatents

    Bose, Pradip; Cher, Chen-Yong; Gupta, Meeta S.

    2016-12-27

    Processor register protection management is disclosed. In embodiments, a method of processor register protection management can include determining a sensitive logical register for executable code generated by a compiler, generating an error-correction table identifying the sensitive logical register, and storing the error-correction table in a memory accessible by a processor. The processor can be configured to generate a duplicate register of the sensitive logical register identified by the error-correction table.

  3. [Medication error management climate and perception for system use according to construction of medication error prevention system].

    PubMed

    Kim, Myoung Soo

    2012-08-01

    The purpose of this cross-sectional study was to examine current status of IT-based medication error prevention system construction and the relationships among system construction, medication error management climate and perception for system use. The participants were 124 patient safety chief managers working for 124 hospitals with over 300 beds in Korea. The characteristics of the participants, construction status and perception of systems (electric pharmacopoeia, electric drug dosage calculation system, computer-based patient safety reporting and bar-code system) and medication error management climate were measured in this study. The data were collected between June and August 2011. Descriptive statistics, partial Pearson correlation and MANCOVA were used for data analysis. Electric pharmacopoeia were constructed in 67.7% of participating hospitals, computer-based patient safety reporting systems were constructed in 50.8%, electric drug dosage calculation systems were in use in 32.3%. Bar-code systems showed up the lowest construction rate at 16.1% of Korean hospitals. Higher rates of construction of IT-based medication error prevention systems resulted in greater safety and a more positive error management climate prevailed. The supportive strategies for improving perception for use of IT-based systems would add to system construction, and positive error management climate would be more easily promoted.

  4. Facilitating Developmental Guidance through Behavioral Management.

    ERIC Educational Resources Information Center

    Davis, Donna H.

    1980-01-01

    The counselor, facilitating classroom development guidance lessons, may experience conflict and difficulty. The management system presented here allows for flexibility and provides sufficient behavioral structure, while encouraging individual expression from students. This behavioral management approach is supportive of, but secondary to,…

  5. Katy Freeway : an evaluation of a second-generation managed lanes project.

    DOT National Transportation Integrated Search

    2013-04-01

    The Katy Freeway Managed Lanes (KML) represents the first operational, multilane managed facility in : Texas and provides an opportunity to benefit from the lessons learned from the project. This study evaluated : multiple aspects of KML and the crit...

  6. Ideas and Inspirations: Good News about Diabetes Prevention and Management in Indian Country

    MedlinePlus

    ... Combined Councils Patient Education Primary Care Provider Risk Management Veteran Resources Community Health Behavioral Health Environmental Health ... Tools Diabetes Education Lesson Plan Outlines Integrating Case Management Into Your Practice [PDF – 290 KB] Integrating DSMES ...

  7. Using video recording to identify management errors in pediatric trauma resuscitation.

    PubMed

    Oakley, Ed; Stocker, Sergio; Staubli, Georg; Young, Simon

    2006-03-01

    To determine the ability of video recording to identify management errors in trauma resuscitation and to compare this method with medical record review. The resuscitation of children who presented to the emergency department of the Royal Children's Hospital between February 19, 2001, and August 18, 2002, for whom the trauma team was activated was video recorded. The tapes were analyzed, and management was compared with Advanced Trauma Life Support guidelines. Deviations from these guidelines were recorded as errors. Fifty video recordings were analyzed independently by 2 reviewers. Medical record review was undertaken for a cohort of the most seriously injured patients, and errors were identified. The errors detected with the 2 methods were compared. Ninety resuscitations were video recorded and analyzed. An average of 5.9 errors per resuscitation was identified with this method (range: 1-12 errors). Twenty-five children (28%) had an injury severity score of >11; there was an average of 2.16 errors per patient in this group. Only 10 (20%) of these errors were detected in the medical record review. Medical record review detected an additional 8 errors that were not evident on the video recordings. Concordance between independent reviewers was high, with 93% agreement. Video recording is more effective than medical record review in detecting management errors in pediatric trauma resuscitation. Management errors in pediatric trauma resuscitation are common and often involve basic resuscitation principles. Resuscitation of the most seriously injured children was associated with fewer errors. Video recording is a useful adjunct to trauma resuscitation auditing.

  8. Science in the public process of ecosystem management: lessons from Hawaii, Southeast Asia, Africa and the US Mainland.

    PubMed

    Gutrich, John; Donovan, Deanna; Finucane, Melissa; Focht, Will; Hitzhusen, Fred; Manopimoke, Supachit; McCauley, David; Norton, Bryan; Sabatier, Paul; Salzman, Jim; Sasmitawidjaja, Virza

    2005-08-01

    Partnerships and co-operative environmental management are increasing worldwide as is the call for scientific input in the public process of ecosystem management. In Hawaii, private landowners, non-governmental organizations, and state and federal agencies have formed watershed partnerships to conserve and better manage upland forested watersheds. In this paper, findings of an international workshop convened in Hawaii to explore the strengths of approaches used to assess stakeholder values of environmental resources and foster consensus in the public process of ecosystem management are presented. Authors draw upon field experience in projects throughout Hawaii, Southeast Asia, Africa and the US mainland to derive a set of lessons learned that can be applied to Hawaiian and other watershed partnerships in an effort to promote consensus and sustainable ecosystem management. Interdisciplinary science-based models can serve as effective tools to identify areas of potential consensus in the process of ecosystem management. Effective integration of scientific input in co-operative ecosystem management depends on the role of science, the stakeholders and decision-makers involved, and the common language utilized to compare tradeoffs. Trust is essential to consensus building and the integration of scientific input must be transparent and inclusive of public feedback. Consideration of all relevant stakeholders and the actual benefits and costs of management activities to each stakeholder is essential. Perceptions and intuitive responses of people can be as influential as analytical processes in decision-making and must be addressed. Deliberative, dynamic and iterative decision-making processes all influence the level of stakeholder achievement of consensus. In Hawaii, application of lessons learned can promote more informed and democratic decision processes, quality scientific analysis that is relevant, and legitimacy and public acceptance of ecosystem management.

  9. Implementing the community health worker model within diabetes management: challenges and lessons learned from programs across the United States.

    PubMed

    Cherrington, Andrea; Ayala, Guadalupe X; Amick, Halle; Allison, Jeroan; Corbie-Smith, Giselle; Scarinci, Isabel

    2008-01-01

    The purpose of this qualitative study was to examine methods of implementation of the community health worker (CHW) model within diabetes programs, as well as related challenges and lessons learned. Semi-structured interviews were conducted with program managers. Four databases (PubMed, CINAHL, ISI Web of Knowledge, PsycInfo), the CDC's 1998 directory of CHW programs, and Google Search Engine were used to identify CHW programs. Criteria for inclusion were: DM program; used CHW strategy; occurred in United States. Two independent reviewers performed content analyses to identify major themes and findings. Sixteen programs were assessed, all but 3 focused on minority populations. Most CHWs were recruited informally; 6 programs required CHWs to have diabetes. CHW roles and responsibilities varied across programs; educator was the most commonly identified role. Training also varied in terms of both content and intensity. All programs gave CHWs remuneration for their work. Common challenges included difficulties with CHW retention, intervention fidelity and issues related to sustainability. Cultural and gender issues also emerged. Examples of lessons learned included the need for community buy-in and the need to anticipate nondiabetes related issues. Lessons learned from these programs may be useful to others as they apply the CHW model to diabetes management within their own communities. Further research is needed to elucidate the specific features of this model necessary to positively impact health outcomes.

  10. Apollo 1 Lessons Learned Show

    NASA Image and Video Library

    2017-01-27

    Mike Ciannilli, the Apollo, Challenger, Columbia Lessons Learned Program manager, welcomes participants to the Apollo 1 Lessons Learned presentation in the Training Auditorium at NASA’s Kennedy Space Center in Florida. The program's theme was "To There and Back Again." Guest panelists included Charlie Duke, former Apollo 16 astronaut and member of the Apollo 1 Emergency Egress Investigation Team; Ernie Reyes, retired, Apollo 1 senior operations engineer; and John Tribe, retired, Apollo 1 Reaction and Control System lead engineer. The event helped pay tribute to the Apollo 1 crew, Gus Grissom, Ed White II, and Roger Chaffee.

  11. Reengineering a database for clinical trials management: lessons for system architects.

    PubMed

    Brandt, C A; Nadkarni, P; Marenco, L; Karras, B T; Lu, C; Schacter, L; Fisk, J M; Miller, P L

    2000-10-01

    This paper describes the process of enhancing Trial/DB, a database system for clinical studies management. The system's enhancements have been driven by the need to maximize the effectiveness of developer personnel in supporting numerous and diverse users, of study designers in setting up new studies, and of administrators in managing ongoing studies. Trial/DB was originally designed to work over a local area network within a single institution, and basic architectural changes were necessary to make it work over the Internet efficiently as well as securely. Further, as its use spread to diverse communities of users, changes were made to let the processes of study design and project management adapt to the working styles of the principal investigators and administrators for each study. The lessons learned in the process should prove instructive for system architects as well as managers of electronic patient record systems.

  12. Characterization of mathematics instructional practises for prospective elementary teachers with varying levels of self-efficacy in classroom management and mathematics teaching

    NASA Astrophysics Data System (ADS)

    Lee, Carrie W.; Walkowiak, Temple A.; Nietfeld, John L.

    2017-03-01

    The purpose of this study was to investigate the relationship between prospective teachers' (PTs) instructional practises and their efficacy beliefs in classroom management and mathematics teaching. A sequential, explanatory mixed-methods design was employed. Results from efficacy surveys, implemented with 54 PTs were linked to a sample of teachers' instructional practises during the qualitative phase. In this phase, video-recorded lessons were analysed based on tasks, representations, discourse, and classroom management. Findings indicate that PTs with higher levels of mathematics teaching efficacy taught lessons characterised by tasks of higher cognitive demand, extended student explanations, student-to-student discourse, and explicit connections between representations. Classroom management efficacy seems to bear influence on the utilised grouping structures. These findings support explicit attention to PTs' mathematics teaching and classroom management efficacy throughout teacher preparation and a need for formative feedback to inform development of beliefs about teaching practises.

  13. Principles of disaster management. Lesson 7: Management leadership styles and methods.

    PubMed

    Cuny, F C

    2000-01-01

    This lesson explores the use of different management leadership styles and methods that are applied to disaster management situations. Leadership and command are differentiated. Mechanisms that can be used to influence others developed include: 1) coercion; 2) reward; 3) position; 4) knowledge; and 5) admiration. Factors that affect leadership include: 1) individual characteristics; 2) competence; 3) experience; 4) self-confidence; 5) judgment; 6) decision-making; and 8) style. Experience and understanding the task are important factors for leadership. Four styles of leadership are developed: 1) directive; 2) supportive; 3) participative; and 4) achievement oriented. Application of each of these styles is discussed. The styles are discussed further as they relate to the various stages of a disaster. The effects of interpersonal relationships and the effects of the environment are stressed. Lastly, leadership does not just happen because a person is appointed as a manager--it must be earned.

  14. Lessons from Management 101: Learning to Manage Ourselves

    ERIC Educational Resources Information Center

    Miller, John A.

    2017-01-01

    The Management 101 Project continues to shape our understanding of what's essential to an introductory general education course in management. Our ongoing challenge is to integrate responsibilities to people (Who needs to learn? Everybody.), to best practices (How can we best learn? Active, experiential methods.), and to the contents of our…

  15. 10 Guidelines for Ecosystem Researchers: Lessons from Missouri

    Treesearch

    David R. Larsen; Stephen R. Shifley; Frank R., III Thompson; Brian L. Brookshire; Daniel C. Dey; Eric W. Kurzejeski; Kristine England

    1997-01-01

    In the early 1990s managers in natural resource agencies in Missouri began asking, "How does ecosystem management relate to our current practices? How might we do a better job of managing large ecosystems?" As they started addressing these questions, several points emerged:Planning and managing ecosystems requires expertise in more...

  16. National Training Course. Emergency Medical Technician. Paramedic. Instructor's Lesson Plans. Module XI. Obstetric/Gynecologic Emergencies.

    ERIC Educational Resources Information Center

    National Highway Traffic Safety Administration (DOT), Washington, DC.

    This instructor's lesson plan guide on obstetric/gynecologic emergencies is one of fifteen modules designed for use in the training of emergency medical technicians (paramedics). Six units of study are presented: (1) anatomy and physiology of the female reproductive system; (2) patient assessment; (3) pathophysiology and management of gynecologic…

  17. National Training Course. Emergency Medical Technician. Paramedic. Instructor's Lesson Plans. Module V. Respiratory System.

    ERIC Educational Resources Information Center

    National Highway Traffic Safety Administration (DOT), Washington, DC.

    This instructor's lesson plan guide on the respiratory system is one of fifteen modules designed for use in the training of emergency medical technicians (paramedics). Five units of study are presented: (1) anatomy and physiology of the respiratory system; (2) pathophysiology assessment of the patient; (3) pathophysiology and management of…

  18. Advanced Dairy Unit for Advanced Livestock Production Curriculum. Instructor's Guide. AGDEX 410/00.

    ERIC Educational Resources Information Center

    Coday, Stan; Stewart, Bob R.

    This instructor's guide contains 18 lessons for teaching advanced dairying in accordance with the Missouri State Board of Education's Vocational Instructional Management System. To make the unit easier for teachers to use, the following materials are provided in the front of the unit: objectives and competencies for each lesson, a references and…

  19. Incorporating Sarbanes-Oxley into a College Accounting Curriculum: Lessons Learned

    ERIC Educational Resources Information Center

    Ragan, Joseph M.; Rizman, Brian J.; Gregory, Jonathan T.

    2007-01-01

    This paper attempts to identify the ways and give examples of how Sarbanes-Oxley compliance can be taught in real time using the SAP R/3 system and the many lessons derived from the experience. The Sarbanes-Oxley Act significantly impacts CEO's, CFO's and public accountants. It also applies to all levels of management. Organizations and their…

  20. Soil Conservation Unit for the Advanced Crop Production and Marketing Course. Instructor's Guide. AGDEX 570.

    ERIC Educational Resources Information Center

    Stewart, Bob R.; And Others

    This instructor's guide contains eight lesson plans for teaching soil conservation in accordance with the Missouri State Board of Education's Vocational Instructional Management System. To make the unit easier for teachers to use, the following materials are provided in the front of the unit: objectives and competencies for each lesson, a…

  1. Computer-Assisted Management of Instruction in Veterinary Public Health

    ERIC Educational Resources Information Center

    Holt, Elsbeth; And Others

    1975-01-01

    Reviews a course in Food Hygiene and Public Health at the University of Illinois College of Veterinary Medicine in which students are sequenced through a series of computer-based lessons or autotutorial slide-tape lessons, the computer also being used to route, test, and keep records. Since grades indicated mastery of the subject, the course will…

  2. Introduction to Animal Reproduction. Instructor Guide [and] Student Reference. Volume 28, Number 5 [and] Volume 28, Number 6.

    ERIC Educational Resources Information Center

    Peiter, Andrea; And Others

    This instructor guide and the corresponding student reference contain seven lessons about animal reproduction for inclusion in Vocational Instructional Management System (VIMS) agricultural education courses. The lessons cover the following topics: the male and female reproductive systems, puberty and the estrous cycle, conception and gestation,…

  3. National Training Course. Emergency Medical Technician. Paramedic. Instructor's Lesson Plans. Module VII. Central Nervous System.

    ERIC Educational Resources Information Center

    National Highway Traffic Safety Administration (DOT), Washington, DC.

    This instructor's lesson plan guide on the central nervous system is one of fifteen modules designed for use in the training of emergency medical technicians. Four units of study are presented: (1) anatomy and physiology; (2) assessment of patients with neurological problems; (3) pathophysiology and management of neurological problems; (4)…

  4. Application of Interactive Multimedia Tools in Teaching Mathematics--Examples of Lessons from Geometry

    ERIC Educational Resources Information Center

    Milovanovic, Marina; Obradovic, Jasmina; Milajic, Aleksandar

    2013-01-01

    This article presents the benefits and importance of using multimedia in the math classes by the selected examples of multimedia lessons from geometry (isometric transformations and regular polyhedra). The research included two groups of 50 first year students of the Faculty of the Architecture and the Faculty of Civil Construction Management.…

  5. How to apply Y2K lessons to patient confidentiality.

    PubMed

    2001-04-01

    Despite current debate over the details of implementing the privacy portion of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, experts say quality managers should continue their planning to comply with the new law. One way to prepare for the sweeping new mandates is to apply the lessons of Y2K to HIPAA.

  6. Implementation of the Better Jobs Better Care Demonstration: Lessons for Long-Term Care Workforce Initiatives

    ERIC Educational Resources Information Center

    Kemper, Peter; Brannon, Diane; Barry, Teta; Stott, Amy; Heier, Brigitt

    2008-01-01

    Purpose: Better Jobs Better Care (BJBC) was a long-term care workforce demonstration that sought to improve recruitment and retention of direct care workers by changing public policy and management practice. The purpose of this article is to document and assess BJBC's implementation, analyze factors affecting implementation, and draw lessons from…

  7. Extending the Capabilities of Internet-Based Research: Lessons from the Field.

    ERIC Educational Resources Information Center

    Tingling, Peter; Parent, Michael; Wade, Michael

    2003-01-01

    Summarizes the existing practices of Internet research and suggests extensions to them (e.g., consideration of new capabilities, such as adaptive questions and higher levels of flexibility and control) based on a large-scale, national Web survey. Lessons learned include the use of a modular design, management of Web traffic, and the higher level…

  8. National Training Course. Emergency Medical Technician. Paramedic. Instructor's Lesson Plans. Module XII. Pediatrics and Neonatal.

    ERIC Educational Resources Information Center

    National Highway Traffic Safety Administration (DOT), Washington, DC.

    This instructor's lesson plan guide on pediatrics and neonatal transport is one of fifteen modules designed for use in the training of emergency medical technicians (paramedics). Five units of study are presented: (1) approach to the pediatric patient including patient assessment; (2) pathophysiology and management of problems unique to the…

  9. Apollo 1 Lessons Learned Show

    NASA Image and Video Library

    2017-01-27

    Ernie Reyes, retired, former Apollo 1 senior operations manager, signs a book for a worker after the Apollo 1 Lessons Learned presentation in the Training Auditorium at NASA's Kennedy Space Center in Florida. The theme of the program was "To there and Back Again." The event helped pay tribute to the Apollo 1 crew, Gus Grissom, Ed White II, and Roger Chaffee.

  10. Nurses' role in medication safety.

    PubMed

    Choo, Janet; Hutchinson, Alison; Bucknall, Tracey

    2010-10-01

    To explore the nurse's role in the process of medication management and identify the challenges associated with safe medication management in contemporary clinical practice. Medication errors have been a long-standing factor affecting consumer safety. The nursing profession has been identified as essential to the promotion of patient safety. A review of literature on medication errors and the use of electronic prescribing in medication errors. Medication management requires a multidisciplinary approach and interdisciplinary communication is essential to reduce medication errors. Information technologies can help to reduce some medication errors through eradication of transcription and dosing errors. Nurses must play a major role in the design of computerized medication systems to ensure a smooth transition to such as system. The nurses' roles in medication management cannot be over-emphasized. This is particularly true when designing a computerized medication system. The adoption of safety measures during decision making that parallel those of the aviation industry safety procedures can provide some strategies to prevent medication error. Innovations in information technology offer potential mechanisms to avert adverse events in medication management for nurses. © 2010 The Authors. Journal compilation © 2010 Blackwell Publishing Ltd.

  11. Lessons learnt from past Flash Floods and Debris Flow events to propose future strategies on risk management

    NASA Astrophysics Data System (ADS)

    Cabello, Angels; Velasco, Marc; Escaler, Isabel

    2010-05-01

    Floods, including flash floods and debris flow events, are one of the most important hazards in Europe regarding both economic and life loss. Moreover, changes in precipitation patterns and intensity are very likely to increase due to the observed and predicted global warming, rising the risk in areas that are already vulnerable to floods. Therefore, it is very important to carry out new strategies to improve flood protection, but it is also crucial to take into account historical data to identify high risk areas. The main objective of this paper is to show a comparative analysis of the flood risk management information compiled in four test-bed basins (Llobregat, Guadalhorce, Gardon d'Anduze and Linth basins) from three different European countries (Spain, France and Switzerland) and to identify which are the lessons learnt from their past experiences in order to propose future strategies on risk management. This work is part of the EU 7th FP project IMPRINTS which aims at reducing loss of life and economic damage through the improvement of the preparedness and the operational risk management of flash flood and debris flow (FF & DF) events. The methodology followed includes the following steps: o Specific survey on the effectivity of the implemented emergency plans and risk management procedures sent to the test-bed basin authorities that participate in the project o Analysis of the answers from the questionnaire and further research on their methodologies for risk evaluation o Compilation of available follow-up studies carried out after major flood events in the four test-bed basins analyzed o Collection of the lessons learnt through a comparative analysis of the previous information o Recommendations for future strategies on risk management based on lessons learnt and management gaps detected through the process As the Floods Directive (FD) already states, the flood risks associated to FF & DF events should be assessed through the elaboration of Flood Risk Management Plans (FRMP) with tailored solutions for each basin, evaluating their flood mitigation potential, promoting environmental objectives and increasing the efficiency of the already adopted measures. The FRMP should focus on prevention (and protection), preparedness and response, and these have been the three main risk management phases of a flood crisis that have been assessed when extracting the lessons learnt from past events. Lessons learnt concerning dissemination through the three previously mentioned phases and also related to education initiatives have also been included. A common response to most of the events described in this paper was to upgrade the meteorological and hydrological forecasting systems, making the forecasting lead-time as large as possible. Another common recommendation from the test-beds was the need to implement and accomplish the land use regulations. All the basins also detected that structural measures are necessary to increase the population's protection level, but replacing the traditional safety mentality by a risk culture based on a comprehensive analysis of the flood risk. The four basins studied have also highlighted the importance of collecting information when FF & DF events occur and creating historic databases that will provide extremely useful information in the future.

  12. The effectiveness of risk management program on pediatric nurses' medication error.

    PubMed

    Dehghan-Nayeri, Nahid; Bayat, Fariba; Salehi, Tahmineh; Faghihzadeh, Soghrat

    2013-09-01

    Medication therapy is one of the most complex and high-risk clinical processes that nurses deal with. Medication error is the most common type of error that brings about damage and death to patients, especially pediatric ones. However, these errors are preventable. Identifying and preventing undesirable events leading to medication errors are the main risk management activities. The aim of this study was to investigate the effectiveness of a risk management program on the pediatric nurses' medication error rate. This study is a quasi-experimental one with a comparison group. In this study, 200 nurses were recruited from two main pediatric hospitals in Tehran. In the experimental hospital, we applied the risk management program for a period of 6 months. Nurses of the control hospital did the hospital routine schedule. A pre- and post-test was performed to measure the frequency of the medication error events. SPSS software, t-test, and regression analysis were used for data analysis. After the intervention, the medication error rate of nurses at the experimental hospital was significantly lower (P < 0.001) and the error-reporting rate was higher (P < 0.007) compared to before the intervention and also in comparison to the nurses of the control hospital. Based on the results of this study and taking into account the high-risk nature of the medical environment, applying the quality-control programs such as risk management can effectively prevent the occurrence of the hospital undesirable events. Nursing mangers can reduce the medication error rate by applying risk management programs. However, this program cannot succeed without nurses' cooperation.

  13. Information Technology Outside Health Care

    PubMed Central

    Tuttle, Mark S.

    1999-01-01

    Non-health-care uses of information technology (IT) provide important lessons for health care informatics that are often overlooked because of the focus on the ways in which health care is different from other domains. Eight examples of IT use outside health care provide a context in which to examine the content and potential relevance of these lessons. Drawn from personal experience, five books, and two interviews, the examples deal with the role of leadership, academia, the private sector, the government, and individuals working in large organizations. The interviews focus on the need to manage technologic change. The lessons shed light on how to manage complexity, create and deploy standards, empower individuals, and overcome the occasional “wrongness” of conventional wisdom. One conclusion is that any health care informatics self-examination should be outward-looking and focus on the role of health care IT in the larger context of the evolving uses of IT in all domains. PMID:10495095

  14. ICRP publication 112. A report of preventing accidental exposures from new external beam radiation therapy technologies.

    PubMed

    Ortiz López, P; Cosset, J M; Dunscombe, P; Holmberg, O; Rosenwald, J C; Pinillos Ashton, L; Vilaragut Llanes, J J; Vatnitsky, S

    2009-08-01

    Disseminating the knowledge and lessons learned from accidental exposures is crucial in preventing re-occurrence. This is particularly important in radiation therapy; the only application of radiation in which very high radiation doses are deliberately given to patients to achieve cure or palliation of disease. Lessons from accidental exposures are, therefore, an invaluable resource for revealing vulnerable aspects of the practice of radiotherapy, and for providing guidance for the prevention of future occurrences. These lessons have successfully been applied to avoid catastrophic events with conventional technologies and techniques. Recommendations, for example, include the independent verification of beam calibration and independent calculation of the treatment times and monitor units for external beam radiotherapy, and the monitoring of patients and their clothes immediately after brachytherapy. New technologies are meant to bring substantial improvement to radiation therapy. However, this is often achieved with a considerable increase in complexity, which in turn brings opportunities for new types of human error and problems with equipment. Dissemination of information on these errors or mistakes as soon as it becomes available is crucial in radiation therapy with new technologies. In addition, information on circumstances that almost resulted in serious consequences (near-misses) is also important, as the same type of events may occur elsewhere. Sharing information about near-misses is thus a complementary important aspect of prevention. Lessons from retrospective information are provided in Sections 2 and 4 of this report. Disseminating lessons learned for serious incidents is necessary but not sufficient when dealing with new technologies. It is of utmost importance to be proactive and continually strive to answer questions such as 'What else can go wrong', 'How likely is it?' and 'What kind of cost-effective choices do I have for prevention?'. These questions are addressed in Sections 3 and 5 of this report. Section 6 contains the conclusions and recommendations. This report is expected to be a valuable resource for radiation oncologists, hospital administrators, medical physicists, technologists, dosimetrists, maintenance engineers, radiation safety specialists, and regulators. While the report applies specifically to new external beam therapies, the general principles for prevention are applicable to the broad range of radiotherapy practices where mistakes could result in serious consequences for the patient and practitioner.

  15. Error management training and simulation education.

    PubMed

    Gardner, Aimee; Rich, Michelle

    2014-12-01

    The integration of simulation into the training of health care professionals provides context for decision making and procedural skills in a high-fidelity environment, without risk to actual patients. It was hypothesised that a novel approach to simulation-based education - error management training - would produce higher performance ratings compared with traditional step-by-step instruction. Radiology technology students were randomly assigned to participate in traditional procedural-based instruction (n = 11) or vicarious error management training (n = 11). All watched an instructional video and discussed how well each incident was handled (traditional instruction group) or identified where the errors were made (vicarious error management training). Students then participated in a 30-minute case-based simulation. Simulations were videotaped for performance analysis. Blinded experts evaluated performance using a predefined evaluation tool created specifically for the scenario. Blinded experts evaluated performance using a predefined evaluation tool created specifically for the scenario The vicarious error management group scored higher on observer-rated performance (Mean = 9.49) than students in the traditional instruction group (Mean = 9.02; p < 0.01). These findings suggest that incorporating the discussion of errors and how to handle errors during the learning session will better equip students when performing hands-on procedures and skills. This pilot study provides preliminary evidence for integrating error management skills into medical curricula and for the design of learning goals in simulation-based education. © 2014 John Wiley & Sons Ltd.

  16. Plant invasions in mountains: Global lessons for better management

    USGS Publications Warehouse

    McDougall, K.L.; Khuroo, A.A.; Loope, L.L.; Parks, C.G.; Pauchard, A.; Reshi, Z.A.; Rushworth, I.; Kueffer, C.

    2011-01-01

    Mountains are one of few ecosystems little affected by plant invasions. However, the threat of invasion is likely to increase because of climate change, greater anthropogenic land use, and continuing novel introductions. Preventive management, therefore, will be crucial but can be difficult to promote when more pressing problems are unresolved and predictions are uncertain. In this essay, we use management case studies from 7 mountain regions to identify common lessons for effective preventive action. The degree of plant invasion in mountains was variable in the 7 regions as was the response to invasion, which ranged from lack of awareness by land managers of the potential impact in Chile and Kashmir to well-organized programs of prevention and containment in the United States (Hawaii and the Pacific Northwest), including prevention at low altitude. In Australia, awareness of the threat grew only after disruptive invasions. In South Africa, the economic benefits of removing alien plants are well recognized and funded in the form of employment programs. In the European Alps, there is little need for active management because no invasive species pose an immediate threat. From these case studies, we identify lessons for management of plant invasions in mountain ecosystems: (i) prevention is especially important in mountains because of their rugged terrain, where invasions can quickly become unmanageable; (ii) networks at local to global levels can assist with awareness raising and better prioritization of management actions; (iii) the economic importance of management should be identified and articulated; (iv) public acceptance of management programs will make them more effective; and (v) climate change needs to be considered. We suggest that comparisons of local case studies, such as those we have presented, have a pivotal place in the proactive solution of global change issues. ?? International Mountain Society.

  17. Experience of quality management system in a clinical laboratory in Nigeria

    PubMed Central

    Sylvester-Ikondu, Ugochukwu; Onwuamah, Chika K.; Salu, Olumuyiwa B.; Ige, Fehintola A.; Meshack, Emily; Aniedobe, Maureen; Amoo, Olufemi S.; Okwuraiwe, Azuka P.; Okhiku, Florence; Okoli, Chika L.; Fasela, Emmanuel O.; Odewale, Ebenezer. O.; Aleshinloye, Roseline O.; Olatunji, Micheal; Idigbe, Emmanuel O.

    2012-01-01

    Issues Quality-management systems (QMS) are uncommon in clinical laboratories in Nigeria, and until recently, none of the nation’s 5 349 clinical laboratories have been able to attain the certifications necessary to begin the process of attaining international accreditation. Nigeria’s Human Virology Laboratory (HVL), however, began implementation of a QMS in 2006, and in 2008 it was determined that the laboratory conformed to the requirements of ISO 9001:2000 (now 2008), making it the first diagnostic laboratory to be certified in Nigeria. The HVL has now applied for the World Health Organization (WHO) accreditation preparedness scheme. The experience of the QMS implementation process and the lessons learned therein are shared here. Description In 2005, two personnel from the HVL spent time studying quality systems in a certified clinical laboratory in Dakar, Senegal. Following this peer-to-peer technical assistance, several training sessions were undertaken by HVL staff, a baseline assessment was conducted, and processes were established. The HVL has monitored its quality indicators and conducted internal and external audits; these analyses (from 2007 to 2009) are presented herein. Lessons learned Although there was improvement in the pre-analytical and analytical indicators analysed and although data-entry errors decreased in the post-analytical process, the delay in returning laboratory test results increased significantly. There were several factors identified as causes for this delay and all of these have now been addressed except for an identified need for automation of some high-volume assays (currently being negotiated). Internal and external audits showed a trend of increasing non-conformities which could be the result of personnel simply becoming lax over time. Application for laboratory accreditation, however, could provide the renewed vigour needed to correct these non-conformities. Recommendation This experience shows that sustainability of the QMS at present is a cause for concern. However, the tiered system of accreditation being developed by WHO–Afro may act as a driving force to preserve the spirit of continual improvement. PMID:29062734

  18. Managing the ice in the waters ahead: lessons from the Titanic.

    PubMed

    Waymack, Pamela M

    2006-07-01

    To navigate carefully through today's rough healthcare waters, healthcare financial managers need to: Plan for the unexpected. Realize that technology alone is not a solution. Refrain from being overconfident

  19. ASK Magazine. No. 13

    NASA Technical Reports Server (NTRS)

    Post, Todd (Editor); Pellen, Charles

    2003-01-01

    Many of the stories in this magazine for NASA project managers are written by project managers, who use anecdotes from their experience to illustrate managerial lessons. This issue also includes features, an interview, and book reviews.

  20. So you want to be a CEO: lessons from the field.

    PubMed

    Rothberg, E D

    2001-01-01

    This article discusses graduate educational options for those seeking to become chief executive officers and examines the subject areas that are important on a practical level. It then discusses six areas that are essential to a successful manager: problem solving, critical thinking, and organizational behavior; breadth of knowledge; financial management; corporate culture; for profit and not for profit, and--politics--internal and external. Each area includes a lesson drawn from experience as a president and CEO. Readers should gain a level of understanding of the scope of responsibilities and skills necessary to succeed in today's health care environment.

  1. Case Management of Dengue: Lessons Learned

    PubMed Central

    Kalayanarooj, Siripen; Srikiatkhachorn, Anon

    2017-01-01

    Abstract The global burden of dengue and its geographic distribution have increased over the past several decades. The introduction of dengue in new areas has often been accompanied by high case-fatality rates. Drawing on the experience in managing dengue cases at the Queen Sirikit National Institute of Child Health in Bangkok, Thailand, this article provides the authors’ perspectives on key clinical lessons to improve dengue-related outcomes. Parallels between this clinical experience and outcomes reported in randomized controlled trials, results of efforts to disseminate practice recommendations, and suggestions for areas for further research are also discussed. PMID:28403440

  2. Catchment-scale stormwater management via economic incentives – An overview and lessons-learned

    USGS Publications Warehouse

    Schuster, W.; Garmestani, A.S.; Green, O.O.; Rhea, l.K.; Roy, Allison; Thurston, H.W.; Myers, Baden Robert; Beecham, Simon; Lucke, Terry; Boogaard, Floris

    2013-01-01

    Long-term field studies of the effectiveness and sustainability of decentralized stormwater management are rare. From 2005-2011, we tested an incentive-based approach to citizen participation in stormwater management in the Shepherd Creek catchment, located in Cincinnati, OH, USA. Hydrologic, biological, and water quality data were characterized in a baseline monitoring effort 2005- 2007. Reverse auctions held successively in 2007 and 2008 engaged citizens to voluntarily bid on stormwater control measures (SCMs); and successful bids led to implementation of SCMs, which led to an enhancement of catchment detention capacity. We tested for attributes of sustainability (coconsideration of social, economic, and environmental (hydrologic, soils, aquatic biology) aspects), and summarize lessons-learned. Our results and outcomes provide a basis for planning future field studies that more fully determine the effectiveness of stormwater management in terms of sustainability.

  3. MAVEN Information Security Governance, Risk Management, and Compliance (GRC): Lessons Learned

    NASA Technical Reports Server (NTRS)

    Takamura, Eduardo; Gomez-Rosa, Carlos A.; Mangum, Kevin; Wasiak, Fran

    2014-01-01

    As the first interplanetary mission managed by the NASA Goddard Space Flight Center, the Mars Atmosphere and Volatile EvolutioN (MAVEN) had three IT security goals for its ground system: COMPLIANCE, (IT) RISK REDUCTION, and COST REDUCTION. In a multiorganizational environment in which government, industry and academia work together in support of the ground system and mission operations, information security governance, risk management, and compliance (GRC) becomes a challenge as each component of the ground system has and follows its own set of IT security requirements. These requirements are not necessarily the same or even similar to each other's, making the auditing of the ground system security a challenging feat. A combination of standards-based information security management based on the National Institute of Standards and Technology (NIST) Risk Management Framework (RMF), due diligence by the Mission's leadership, and effective collaboration among all elements of the ground system enabled MAVEN to successfully meet NASA's requirements for IT security, and therefore meet Federal Information Security Management Act (FISMA) mandate on the Agency. Throughout the implementation of GRC on MAVEN during the early stages of the mission development, the Project faced many challenges some of which have been identified in this paper. The purpose of this paper is to document these challenges, and provide a brief analysis of the lessons MAVEN learned. The historical information documented herein, derived from an internal pre-launch lessons learned analysis, can be used by current and future missions and organizations implementing and auditing GRC.

  4. Lessons learned applying CASE methods/tools to Ada software development projects

    NASA Technical Reports Server (NTRS)

    Blumberg, Maurice H.; Randall, Richard L.

    1993-01-01

    This paper describes the lessons learned from introducing CASE methods/tools into organizations and applying them to actual Ada software development projects. This paper will be useful to any organization planning to introduce a software engineering environment (SEE) or evolving an existing one. It contains management level lessons learned, as well as lessons learned in using specific SEE tools/methods. The experiences presented are from Alpha Test projects established under the STARS (Software Technology for Adaptable and Reliable Systems) project. They reflect the front end efforts by those projects to understand the tools/methods, initial experiences in their introduction and use, and later experiences in the use of specific tools/methods and the introduction of new ones.

  5. Online survey software as a data collection tool for medical education: A case study on lesson plan assessment

    PubMed Central

    Kimiafar, Khalil; Sarbaz, Masoumeh; Sheikhtaheri, Abbas

    2016-01-01

    Background: There are no general strategies or tools to evaluate daily lesson plans; however, assessments conducted using traditional methods usually include course plans. This study aimed to evaluate the strengths and weaknesses of online survey software in collecting data on education in medical fields and the application of such softwares to evaluate students' views and modification of lesson plans. Methods: After investigating the available online survey software, esurveypro was selected for assessing daily lesson plans. After using the software for one semester, a questionnaire was prepared to assess the advantages and disadvantages of this method and students’ views in a cross-sectional study. Results: The majority of the students (51.7%) rated the evaluation of classes per session (lesson plans) using the online survey as useful or very useful. About 51% (n=36) of the students considered this method effective in improving the management of each session, 67.1% (n=47) considered it effective in improving the management of sessions for the next semester, and 51.4% (n=36) said it had a high impact on improving the educational content of subsequent sessions. Finally, 61.4% (n=43) students expressed high and very high levels of satisfaction with using an online survey at each session. Conclusion: The use of online surveys may be appropriate to improve lesson plans and educational planning at different levels. This method can be used for other evaluations and for assessing people’s opinions at different levels of an educational system. PMID:28491839

  6. Lessons Learned from Ares I Upper Stage Structures and Thermal Design

    NASA Technical Reports Server (NTRS)

    Ahmed, Rafiq

    2012-01-01

    The Ares 1 Upper Stage was part of the vehicle intended to succeed the Space Shuttle as the United States manned spaceflight vehicle. Although the Upper Stage project was cancelled, there were many lessons learned that are applicable to future vehicle design. Lessons learned that are briefly detailed in this Technical Memorandum are for specific technical areas such as tank design, common bulkhead design, thrust oscillation, control of flight and slosh loads, purge and hazardous gas system. In addition, lessons learned from a systems engineering and vehicle integration perspective are also included, such as computer aided design and engineering, scheduling, and data management. The need for detailed systems engineering in the early stages of a project is emphasized throughout this report. The intent is that future projects will be able to apply these lessons learned to keep costs down, schedules brief, and deliver products that perform to the expectations of their customers.

  7. Integrated management of childhood illness: a summary of first experiences.

    PubMed Central

    Lambrechts, T.; Bryce, J.; Orinda, V.

    1999-01-01

    The strategy of Integrated Management of Childhood Illness (IMCI) aims to reduce child mortality and morbidity in developing countries by combining improved management of common childhood illnesses with proper nutrition and immunization. The strategy includes interventions to improve the skills of health workers, the health system, and family and community practices. This article describes the experience of the first countries to adopt and implement the IMCI interventions, the clinical guidelines dealing with the major causes of morbidity and mortality in children, and the training package on these guidelines for health workers in first-level health facilities. The most relevant lessons learned and how these lessons have served as a basis for developing a broader IMCI strategy are described. PMID:10444882

  8. Rapid Spacecraft Development: Results and Lessons Learned

    NASA Technical Reports Server (NTRS)

    Watson, William A.

    2002-01-01

    The Rapid Spacecraft Development Office (RSDO) at NASA's Goddard Space Flight Center is responsible for the management and direction of a dynamic and versatile program for the definition, competition, and acquisition of multiple indefinite delivery and indefinite quantity contracts - resulting in a catalog of spacecraft buses. Five spacecraft delivery orders have been placed by the RSDO and one spacecraft has been launched. Numerous concept and design studies have been performed, most with the intent of leading to a future spacecraft acquisition. A collection of results and lessons learned is recorded to highlight management techniques, methods and processes employed in the conduct of spacecraft acquisition. Topics include working relationships under fixed price delivery orders, price and value, risk management, contingency reserves, and information restrictions.

  9. Exporting the Buyers Health Care Action Group Purchasing Model: Lessons from Other Communities

    PubMed Central

    Christianson, Jon B; Feldman, Roger

    2005-01-01

    When first implemented in Minneapolis and St. Paul, Minnesota, the Buyers Health Care Action Group's (BHCAG) purchasing approach received considerable attention as an employer-managed, consumer-driven health care model embodying many of the principles of managed competition. First BHCAG and, later, a for-profit management company attempted to export this model to other communities. Their efforts were met with resistance from local hospitals and, in many cases, apathy by employers who were expected to be supportive. This experience underscores several difficulties that appear to be inherent in implementing purchasing models based on competing care systems. It also, once again, suggests caution in drawing lessons from community-level experiments in purchasing health care. PMID:15787957

  10. A qualitative content analysis of global health engagements in Peacekeeping and Stability Operations Institute's stability operations lessons learned and information management system.

    PubMed

    Nang, Roberto N; Monahan, Felicia; Diehl, Glendon B; French, Daniel

    2015-04-01

    Many institutions collect reports in databases to make important lessons-learned available to their members. The Uniformed Services University of the Health Sciences collaborated with the Peacekeeping and Stability Operations Institute to conduct a descriptive and qualitative analysis of global health engagements (GHEs) contained in the Stability Operations Lessons Learned and Information Management System (SOLLIMS). This study used a summative qualitative content analysis approach involving six steps: (1) a comprehensive search; (2) two-stage reading and screening process to identify first-hand, health-related records; (3) qualitative and quantitative data analysis using MAXQDA, a software program; (4) a word cloud to illustrate word frequencies and interrelationships; (5) coding of individual themes and validation of the coding scheme; and (6) identification of relationships in the data and overarching lessons-learned. The individual codes with the most number of text segments coded included: planning, personnel, interorganizational coordination, communication/information sharing, and resources/supplies. When compared to the Department of Defense's (DoD's) evolving GHE principles and capabilities, the SOLLIMS coding scheme appeared to align well with the list of GHE capabilities developed by the Department of Defense Global Health Working Group. The results of this study will inform practitioners of global health and encourage additional qualitative analysis of other lessons-learned databases. Reprint & Copyright © 2015 Association of Military Surgeons of the U.S.

  11. Girls' Activity Levels and Lesson Contexts in Middle School PE: TAAG Baseline

    PubMed Central

    McKENZIE, THOMAS L.; CATELLIER, DIANE J.; CONWAY, TERRY; LYTLE, LESLIE A.; GRIESER, MIRA; WEBBER, LARRY A.; PRATT, CHARLOTTE A.; ELDER, JOHN P.

    2008-01-01

    Purpose To assess girls' physical activity (PA) in middle school physical education (PE) as it relates to field site, lesson context and location, teacher gender, and class composition. Methods We observed girls' PA levels, lesson contexts, and activity promotion by teachers in 431 lessons in 36 schools from six field sites participating in the Trial of Activity for Adolescent Girls. Interobserver reliabilities exceeded 90% for all three categories. Data were analyzed using mixed-model ANOVA with controls for clustering effects by field site and school. Results Mean lesson length was 37.3 (± 9.4) min. Time (13.9 ± 7.0 min) and proportion of lessons (37.9 ± 18.5%) spent in moderate to vigorous PA (MVPA), and time (4.8 ± 4.2 min) and proportion of lessons (13.1 ± 11.7%) in vigorous PA (VPA) differed by field site (P < 0.004). Lesson time for instructional contexts differed by field site, with overall proportions as follows: game play (27.3%), management (26.1%), fitness activities (19.7%), skill drills (12.1%), knowledge (10.6%), and free play (4.4%). Coed classes were 7.9 min longer than girls-only classes (P = 0.03). Although 27 s shorter, outdoor lessons were more intense (MVPA% = 45.7 vs 33.7% of lesson, P < 0.001) and provided 4.0 more MVPA minutes (P < 0.001). MVPA, VPA, and lesson contexts did not differ by teacher gender. There was little direct promotion of PA by teachers during lessons. Conclusions Substantial variation in the conduct of PE exists. Proportion of lesson time girls spent accruing MVPA (i.e., 37.9%) fell short of the Healthy People 2010 objective of 50%. Numerous possibilities exist for improving girls' PA in PE. PMID:16826019

  12. Less of Me

    NASA Technical Reports Server (NTRS)

    Owen, Tim

    2002-01-01

    The author warns that micromanagement of projects can provoke defensive attitudes among employees, and inhibits their professional development. Nevertheless, project managers should still demand some accountability from their subordinates. The article draws upon his own experiences as a NASA project manager and under NASA project managers for these lessons.

  13. An Exit Strategy Not a Winning Strategy? Intelligence Lessons from the British ’Emergency’ in South Arabia, 1963-67

    DTIC Science & Technology

    2012-12-14

    comments came in so thick and fast that capturing them was itself a testing experience! In addition to the above Art of War team, I was very fortunate...via email throughout the research and writing period. Sincere thanks to all; nonetheless, all errors and omissions are my own. Finally, I must pay...

  14. Team safety and innovation by learning from errors in long-term care settings.

    PubMed

    Buljac-Samardžić, Martina; van Woerkom, Marianne; Paauwe, Jaap

    2012-01-01

    Team safety and team innovation are underexplored in the context of long-term care. Understanding the issues requires attention to how teams cope with error. Team managers could have an important role in developing a team's error orientation and managing team membership instabilities. The aim of this study was to examine the impact of team member stability, team coaching, and a team's error orientation on team safety and innovation. A cross-sectional survey method was employed within 2 long-term care organizations. Team members and team managers received a survey that measured safety and innovation. Team members assessed member stability, team coaching, and team error orientation (i.e., problem-solving and blaming approach). The final sample included 933 respondents from 152 teams. Stable teams and teams with managers who take on the role of coach are more likely to adopt a problem-solving approach and less likely to adopt a blaming approach toward errors. Both error orientations are related to team member ratings of safety and innovation, but only the blaming approach is (negatively) related to manager ratings of innovation. Differences between members' and managers' ratings of safety are greater in teams with relatively high scores for the blaming approach and relatively low scores for the problem-solving approach. Team coaching was found to be positively related to innovation, especially in unstable teams. Long-term care organizations that wish to enhance team safety and innovation should encourage a problem-solving approach and discourage a blaming approach. Team managers can play a crucial role in this by coaching team members to see errors as sources of learning and improvement and ensuring that individuals will not be blamed for errors.

  15. Errors and Understanding: The Effects of Error-Management Training on Creative Problem-Solving

    ERIC Educational Resources Information Center

    Robledo, Issac C.; Hester, Kimberly S.; Peterson, David R.; Barrett, Jamie D.; Day, Eric A.; Hougen, Dean P.; Mumford, Michael D.

    2012-01-01

    People make errors in their creative problem-solving efforts. The intent of this article was to assess whether error-management training would improve performance on creative problem-solving tasks. Undergraduates were asked to solve an educational leadership problem known to call for creative thought where problem solutions were scored for…

  16. Predictors of Success for Community-Driven Water Quality Management--Lessons from Three Catchments in New Zealand

    ERIC Educational Resources Information Center

    Tyson, Ben; Unson, Christine; Edgar, Nick

    2017-01-01

    Three community engagement projects on the South Island of New Zealand are enacting education and communication initiatives to improve the uptake of best management practices on farms regarding nutrient management for improving water quality. Understanding the enablers and barriers to effective community-based catchment management is fundamental…

  17. Small Business Management. Instructor's Manual. Volume I. Third Edition.

    ERIC Educational Resources Information Center

    Jeanneau, Joseph A.; And Others

    The instructor's manual is one of four prepared as a guide in conducting a small Business Management course for American Indians to prepare them for jobs as owners/managers of their own businesses and for management positions with business owned by bonds, cooperatives, and others. The manual contains lesson plans, suggested methodologies, and…

  18. Messy world: managing dynamic landscape.

    Treesearch

    Sally Duncan

    1999-01-01

    What lessons does historical disturbance hold for the management of future landscapes? Fred Swanson, a researcher at the Pacific Northwest Research Station and John Cissel, research liaison for the Willamette NF, are members of a team of scientists and land managers who are examining the way we think about and manage landscapes.The team found that past...

  19. Business Faculty Time Management: Lessons Learned from the Trenches

    ERIC Educational Resources Information Center

    Cummings, Richard G.; Holmes, Linda E.

    2009-01-01

    Teaching, research, and service expectations of the academic profession may sometimes seem overwhelming. Although much has been written about time management in general, there has not been much written about time management in the academic professions and even less written about time management for academics in the business disciplines. This paper…

  20. Using Conflict-Management Surveys to Extricate Research out of the "Ivory Tower": An Experiential Learning Exercise

    ERIC Educational Resources Information Center

    Anakwe, Uzoamaka P.; Purohit, Yasmin S.

    2006-01-01

    Management scholars have encouraged newer approaches to management education combining cognitive lessons with active experiential activities. This article describes how surveys, originally intended for collecting conflict-management data, can be introduced in the classroom to catalyze a deeper understanding of conflict. This article exemplifies…

  1. Medical errors in primary care clinics – a cross sectional study

    PubMed Central

    2012-01-01

    Background Patient safety is vital in patient care. There is a lack of studies on medical errors in primary care settings. The aim of the study is to determine the extent of diagnostic inaccuracies and management errors in public funded primary care clinics. Methods This was a cross-sectional study conducted in twelve public funded primary care clinics in Malaysia. A total of 1753 medical records were randomly selected in 12 primary care clinics in 2007 and were reviewed by trained family physicians for diagnostic, management and documentation errors, potential errors causing serious harm and likelihood of preventability of such errors. Results The majority of patient encounters (81%) were with medical assistants. Diagnostic errors were present in 3.6% (95% CI: 2.2, 5.0) of medical records and management errors in 53.2% (95% CI: 46.3, 60.2). For management errors, medication errors were present in 41.1% (95% CI: 35.8, 46.4) of records, investigation errors in 21.7% (95% CI: 16.5, 26.8) and decision making errors in 14.5% (95% CI: 10.8, 18.2). A total of 39.9% (95% CI: 33.1, 46.7) of these errors had the potential to cause serious harm. Problems of documentation including illegible handwriting were found in 98.0% (95% CI: 97.0, 99.1) of records. Nearly all errors (93.5%) detected were considered preventable. Conclusions The occurrence of medical errors was high in primary care clinics particularly with documentation and medication errors. Nearly all were preventable. Remedial intervention addressing completeness of documentation and prescriptions are likely to yield reduction of errors. PMID:23267547

  2. National Training Course. Emergency Medical Technician. Paramedic. Instructor's Lesson Plans. Module VIII. Soft Tissue Injuries.

    ERIC Educational Resources Information Center

    National Highway Traffic Safety Administration (DOT), Washington, DC.

    This instructor's lesson plan guide on soft tissue injuries is one of fifteen modules designed for use in the training of emergency medical technicians (paramedics). Six units of study are presented: (1) anatomy and physiology of the skin; (2) patient assessment for soft-tissue injuries; (3) pathophysiology and management of soft tissue injuries;…

  3. Judging the Quality of Teaching in Lessons: Some Thoughts Prompted by Ofsted's Subsidiary Guidance on Teaching Style

    ERIC Educational Resources Information Center

    Richards, Colin

    2014-01-01

    Lesson observations involving judgements of teaching quality are a regular feature of classroom life. Such observations and judgements are made by senior and middle managers in schools and also, very significantly, by Ofsted inspectors as a major component of their judgement on the quality of teaching in a school. Using the example of Ofsted…

  4. The English Teacher's Survival Guide: Ready-To-Use Techniques & Materials for Grades 7-12. 2nd Edition

    ERIC Educational Resources Information Center

    Brandvik, Mary Lou; McKnight, Katherine S.

    2011-01-01

    This unique time-saving book is packed with tested techniques and materials to assist new and experienced English teachers with virtually every phase of their job from lesson planning to effective discipline techniques. The book includes 175 easy-to-understand strategies, lessons, checklists, and forms for effective classroom management and over…

  5. Transformation of an academic medical center: lessons learned from restructuring and downsizing.

    PubMed

    Woodard, B; Fottler, M D; Kilpatrick, A O

    1999-01-01

    This article reviews management literature on health care transformation and describes the processes, including restructuring, job redesign, and downsizing, involved in one academic medical center's experience. The article concludes with lessons learned at each of the stages of the transformation process: planning, implementation, and process continuation. Managerial implications for similar transformation efforts in other health care organizations are suggested.

  6. MSFC Skylab lessons learned

    NASA Technical Reports Server (NTRS)

    1974-01-01

    Key lessons learned during the Skylab Program that could have impact on on-going and future programs are presented. They present early and sometimes subjective opinions; however, they give insights into key areas of concern. These experiences from a complex space program management and space flight serve as an early assessment to provide the most advantage to programs underway. References to other more detailed reports are provided.

  7. Elements for Effective Management of Operating Pump and Treat Systems

    EPA Pesticide Factsheets

    This fact sheet summarizes key aspects of effective management for operating pump and treat (P&T) systems based on lessons learned from conducting optimization evaluations at 20 Superfund-financed P&T systems.

  8. Iatrogenic disease management: moderating medication errors and risks in a pharmacy benefit management environment.

    PubMed

    Nair, Vinit; Salmon, J Warren; Kaul, Alan F

    2007-12-01

    Disease Management (DM) programs have advanced to address costly chronic disease patterns in populations. This is in part due to the programs' significant clinical and economical value, coupled with interest by pharmaceutical manufacturers, managed care organizations, and pharmacy benefit management firms. While cost containment realizations for many such interventions have been less than anticipated, this article explores potentials in marrying Medication Error Risk Reduction into DM programs within managed care environments. Medication errors are an emergent serious problem now gaining attention in US health policy. They represent a failure within population-based health programs because they remain significant cost drivers. Therefore, medication errors should be addressed in an organized fashion, with DM being a worthy candidate for piggybacking such programs to achieve the best synergistic effects.

  9. Classifying nursing errors in clinical management within an Australian hospital.

    PubMed

    Tran, D T; Johnson, M

    2010-12-01

    Although many classification systems relating to patient safety exist, no taxonomy was identified that classified nursing errors in clinical management. To develop a classification system for nursing errors relating to clinical management (NECM taxonomy) and to describe contributing factors and patient consequences. We analysed 241 (11%) self-reported incidents relating to clinical management in nursing in a metropolitan hospital. Descriptive analysis of numeric data and content analysis of text data were undertaken to derive the NECM taxonomy, contributing factors and consequences for patients. Clinical management incidents represented 1.63 incidents per 1000 occupied bed days. The four themes of the NECM taxonomy were nursing care process (67%), communication (22%), administrative process (5%), and knowledge and skill (6%). Half of the incidents did not cause any patient harm. Contributing factors (n=111) included the following: patient clinical, social conditions and behaviours (27%); resources (22%); environment and workload (18%); other health professionals (15%); communication (13%); and nurse's knowledge and experience (5%). The NECM taxonomy provides direction to clinicians and managers on areas in clinical management that are most vulnerable to error, and therefore, priorities for system change management. Any nurses who wish to classify nursing errors relating to clinical management could use these types of errors. This study informs further research into risk management behaviour, and self-assessment tools for clinicians. Globally, nurses need to continue to monitor and act upon patient safety issues. © 2010 The Authors. International Nursing Review © 2010 International Council of Nurses.

  10. Report from the School of Experience: Lessons-Learned on NASA's EOS/ICESat Mission

    NASA Technical Reports Server (NTRS)

    Anselm, William

    2003-01-01

    Abstract-NASA s Earth Observing System EOS) Ice, Cloud, and Land Elevation Satellite (ICESat) mission was one of the first missions under Goddard Space Flight Center s (then-) new Rapid Spacecraft Development Office. This paper explores the lessons-learned under the ICESat successful implementation and launch, focusing on four areas: Procurement., Management, Technical, and Launch and Early Operations. Each of these areas is explored in a practical perspective of communication, the viewpoint of the players, and the interactions among the organizations. Conclusions and lessons-learned are summarized in the final section.

  11. Recovering real money with a contract management system.

    PubMed

    Lang, Kevin; Williams, Bethany

    2003-12-01

    A payment error here, a payment error there--pretty soon, you're talking about real money. Contract and underpayment management systems can pay for themselves by unearthing tiny errors that add up to a lot of lost cash.

  12. "Doctor Jazz": Lessons that medical professionals can learn from jazz musicians.

    PubMed

    van Ark, Allard E; Wijnen-Meijer, Marjo

    2018-04-24

    The worlds of a physician and a jazz musician seem entirely different. Various studies, however, relating the concepts behind jazz music to medical practice and education, have been published. The aim of this essayistic review is to summarize previously described concepts behind jazz music and its required artistic skills that could be translated to medicine, encouraging doctors, medical students and medical educators to see their professional environment from a different perspective. A systematic search was conducted using PubMed, Embase, and ERIC databases, combining keywords with regard to jazz, medicine and medical education. Background information concerning jazz music and several jazz musicians was retrieved through an additional nonsystematic search using Google Scholar. Lessons with regard to improvisational skills, both in communication with patients and in a technical context, communication skills, leadership, interprofessional teamwork and coping with errors are presented. Doctors and medical students could learn various lessons from jazz music performance and jazz musicians. The potential and the possibilities of implementing jazz into the medical curriculum, in order to contribute to the development of professional skills and attitudes of medical students, could be explored further.

  13. Integrating TeamSTEPPS® into ambulatory reproductive health care: Early successes and lessons learned.

    PubMed

    Paul, Maureen E; Dodge, Laura E; Intondi, Evelyn; Ozcelik, Guzey; Plitt, Ken; Hacker, Michele R

    2017-04-01

    Most medical teamwork improvement interventions have occurred in hospitals, and more efforts are needed to integrate them into ambulatory care settings. In 2014, Affiliates Risk Management Services, Inc. (ARMS), the risk management services organization for a large network of reproductive health care organizations in the United States, launched a voluntary 5-year initiative to implement a medical teamwork system in this network using the TeamSTEPPS model. This article describes the ARMS initiative and progress made during the first 2 years, including lessons learned. The ARMS TeamSTEPPS program consists of the following components: preparation of participating organizations, TeamSTEPPS master training, implementation of teamwork improvement programs, and evaluation. We used self-administered questionnaires to assess satisfaction with the ARMS program and with the master training course. In the first 2 years, 20 organizations enrolled. Participants found the preparation phase valuable and were highly satisfied with the master training course. Although most attendees felt that the course imparted the knowledge and tools critical for TeamSTEPPS implementation, they identified time restraints and competing initiatives as potential barriers. The project team has learned valuable lessons about obtaining buy-in, consolidating the change teams, making the curriculum relevant, and evaluation. Ambulatory care settings require innovative approaches to integration of teamwork improvement systems. Evaluating and sharing lessons learned will help to hone best practices as we navigate this new frontier in the field of patient safety. © 2017 American Society for Healthcare Risk Management of the American Hospital Association.

  14. Performance and Evaluation of the Global Modeling and Assimilation Office Observing System Simulation Experiment

    NASA Technical Reports Server (NTRS)

    Prive, Nikki; Errico, R. M.; Carvalho, D.

    2018-01-01

    The National Aeronautics and Space Administration Global Modeling and Assimilation Office (NASA/GMAO) has spent more than a decade developing and implementing a global Observing System Simulation Experiment framework for use in evaluting both new observation types as well as the behavior of data assimilation systems. The NASA/GMAO OSSE has constantly evolved to relect changes in the Gridpoint Statistical Interpolation data assimiation system, the Global Earth Observing System model, version 5 (GEOS-5), and the real world observational network. Software and observational datasets for the GMAO OSSE are publicly available, along with a technical report. Substantial modifications have recently been made to the NASA/GMAO OSSE framework, including the character of synthetic observation errors, new instrument types, and more sophisticated atmospheric wind vectors. These improvements will be described, along with the overall performance of the current OSSE. Lessons learned from investigations into correlated errors and model error will be discussed.

  15. Issues in NASA program and project management

    NASA Technical Reports Server (NTRS)

    Hoffman, Edward J. (Editor)

    1994-01-01

    This volume is the eighth in an ongoing series addressing current topics and lessons learned in NASA program and project management. Articles in this volume cover the following topics: (1) power sources for the Galileo and Ulysses Missions; (2) managing requirements; (3) program control of the Tropical Rainfall Measuring Mission; (4) project management method; (5) career development for project managers; and (6) resources for NASA managers.

  16. Issues in NASA program and project management

    NASA Technical Reports Server (NTRS)

    Hoban, Francis T. (Editor)

    1989-01-01

    This new collection of papers on aerospace management issues contains a history of NASA program and project management, some lessons learned in the areas of management and budget from the Space Shuttle Program, an analysis of tools needed to keep large multilayer programs organized and on track, and an update of resources for NASA managers. A wide variety of opinions and techniques are presented.

  17. Regional Traffic Incident Management Programs : implementation guide

    DOT National Transportation Integrated Search

    2000-11-01

    The purpose of this document is to assist organizations and their leaders in implementing and sustaining regional traffic incident management programs, both by examining some successful models, and by considering some of the lessons learned by early ...

  18. Risk management integration into complex project organizations

    NASA Technical Reports Server (NTRS)

    Fisher, K.; Greanias, G.; Rose, J.; Dumas, R.

    2002-01-01

    This paper describes the approach used in designing and adapting the SIRTF prototype, discusses some of the lessons learned in developing the SIRTF prototype, and explains the adaptability of the risk management database to varying levels project complexity.

  19. Performance Management and Reward

    NASA Astrophysics Data System (ADS)

    Yiannis, Triantafyllopoulos; Ioannis, Seimenis; Nikolaos, Konstantopoulos

    2009-08-01

    The article aims to examine, current Performance Management practices on Reward, financial or non-financial using lessons from the literature and the results of a qualitative analysis as these revealed from the interview of some executive members of Greek companies.

  20. What is Climate Leadership: Examples and Lessons Learned in Supply Chain Management Webinar

    EPA Pesticide Factsheets

    Organizations that have developed comprehensive greenhouse gas inventories and aggressive emissions reduction goals discuss their strategies for managing greenhouse gases in their organizational supply chains and use of EPA Supply Chain resources.

  1. Integrated corridor management : implementation guide and lessons learned.

    DOT National Transportation Integrated Search

    2012-02-01

    This implementation guide is intended for use by adopters of integrated corridor management (ICM) approaches and strategies to address congestion and travel time reliability issues within specific travel corridors. It introduces the topic of ICM and ...

  2. Essentials of Enrollment Management: Cases in the Field

    ERIC Educational Resources Information Center

    Black, Jim

    2004-01-01

    In AACRAO's new publication Essentials of Enrollment Management: Cases in the Field experts in enrollment management representing all types of institutions reveal the evolution of the enrollment strategies implemented at their institutions, the results, and the lessons learned. The introductory chapter provides an overview of themes and models…

  3. 76 FR 69292 - Aging Management of Stainless Steel Structures and Components in Treated Borated Water

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-11-08

    ... NUCLEAR REGULATORY COMMISSION [NRC-2011-0256] Aging Management of Stainless Steel Structures and... Stainless Steel Structures and Components in Treated Borated Water.'' This LR-ISG revises the guidance in...) and Generic Aging Lessons Learned (GALL) Report for the aging management of stainless steel structures...

  4. Responsibility Center Management: Lessons from 25 Years of Decentralized Management.

    ERIC Educational Resources Information Center

    Strauss, Jon C.; Curry, John R.

    Decentralization of authority is a natural act in universities, but decentralization of responsibility is not. A problem faced by universities is the decoupling of academic authority from financial responsibility. The solution proposed in this book for the coupling is Responsibility Center Management (RCM), also called Revenue Responsibility…

  5. Lessons from Literature: Blending Academic Perspective with Management Practices

    ERIC Educational Resources Information Center

    Kapur, Surbhi; Mohanty, Pooja

    2014-01-01

    The present paper studies the role literature can play in management in general and in leadership, organizational behavior and communication in particular. Literature normally gets a skeptical reception in management studies. The paper discusses the relevance of literature for a better understanding of human behaviour and a judicious discernment…

  6. Teaching Self-Management Strategies to Adolescents.

    ERIC Educational Resources Information Center

    Young, K. Richard; And Others

    This book presents a behavioral program to teach adolescents basic self-management skills; two chapters provide the theoretical basis for the program and four chapters supply sample lesson plans. The first chapter is an introduction to behavioral self-management. It proposes a behavior change model with four major components: assessment,…

  7. Systems Management for Force Modernization Equipment.

    DTIC Science & Technology

    1982-04-15

    PERT (New York: John Wiley & Sons, Inc., 1963), p. ’𔄁. 8. Fred Luthans, Introduction to Management (New York: McGraw- Hill Book Company, 1976), p...34Fielding Army Systems: Experiences and Lessons Learned." C, Vol. 3, No. 4, Autumn, 1980. Luthans, Fred. Introduction to Management . New York: McGraw

  8. Managing Evaluation in a Federal Public Health Setting

    ERIC Educational Resources Information Center

    Schooley, Michael W.

    2009-01-01

    The author, a federal manager who leads development and maintenance of evaluation for specific public health programs at the Centers for Disease Control and Prevention, tells the story of developing an evaluation unit in the Office on Smoking and Health. Lessons about managing evaluation, including his practices and related principles, are…

  9. Changing Course Management Systems: Lessons Learned

    ERIC Educational Resources Information Center

    Smart, Kathy A.; Meyer, Katrina A.

    2005-01-01

    During 2003, the North Dakota University System began to be concerned about the cost of supporting multiple course management systems. Since 1997, the 11 NDUS institutions had used 9 different course management packages, including one homegrown product (HTMLeZ) and such proprietary products as Blackboard, WebCT, and e-College. The University of…

  10. Consulting by Business College Academics: Lessons for Business Communication Courses

    ERIC Educational Resources Information Center

    Dave, Anish

    2009-01-01

    Business communication (BC) is a crucial aspect of management consulting. BC scholars have widely studied the relationship between BC and management consulting, including consulting by BC academics. A limited review of the studies of management consulting, including consulting done by business college academics, hereafter referred to simply as…

  11. Keys to success for data-driven decision making: Lessons from participatory monitoring and collaborative adaptive management

    USDA-ARS?s Scientific Manuscript database

    Recent years have witnessed a call for evidence-based decisions in conservation and natural resource management, including data-driven decision-making. Adaptive management (AM) is one prevalent model for integrating scientific data into decision-making, yet AM has faced numerous challenges and limit...

  12. Hubble Space Telescope: SRM/QA observations and lessons learned

    NASA Technical Reports Server (NTRS)

    Rodney, George A.

    1990-01-01

    The Hubble Space Telescope (HST) Optical Systems Board of Investigation was established on July 2, 1990 to review, analyze, and evaluate the facts and circumstances regarding the manufacture, development, and testing of the HST Optical Telescope Assembly (OTA). Specifically, the board was tasked to ascertain what caused the spherical aberration and how it escaped notice until on-orbit operation. The error that caused the on-orbit spherical aberration in the primary mirror was traced to the assembly process of the Reflective Null Corrector, one of the three Null Correctors developed as special test equipment (STE) to measure and test the primary mirror. Therefore, the safety, reliability, maintainability, and quality assurance (SRM&QA) investigation covers the events and the overall product assurance environment during the manufacturing phase of the primary mirror and Null Correctors (from 1978 through 1981). The SRM&QA issues that were identified during the HST investigation are summarized. The crucial product assurance requirements (including nonconformance processing) for the HST are examined. The history of Quality Assurance (QA) practices at Perkin-Elmer (P-E) for the period under investigation are reviewed. The importance of the information management function is discussed relative to data retention/control issues. Metrology and other critical technical issues also are discussed. The SRM&QA lessons learned from the investigation are presented along with specific recommendations. Appendix A provides the MSFC SRM&QA report. Appendix B provides supplemental reference materials. Appendix C presents the findings of the independent optical consultants, Optical Research Associates (ORA). Appendix D provides further details of the fault-tree analysis portion of the investigation process.

  13. Voluntary Medication Error Reporting by ED Nurses: Examining the Association With Work Environment and Social Capital.

    PubMed

    Farag, Amany; Blegen, Mary; Gedney-Lose, Amalia; Lose, Daniel; Perkhounkova, Yelena

    2017-05-01

    Medication errors are one of the most frequently occurring errors in health care settings. The complexity of the ED work environment places patients at risk for medication errors. Most hospitals rely on nurses' voluntary medication error reporting, but these errors are under-reported. The purpose of this study was to examine the relationship among work environment (nurse manager leadership style and safety climate), social capital (warmth and belonging relationships and organizational trust), and nurses' willingness to report medication errors. A cross-sectional descriptive design using a questionnaire with a convenience sample of emergency nurses was used. Data were analyzed using descriptive, correlation, Mann-Whitney U, and Kruskal-Wallis statistics. A total of 71 emergency nurses were included in the study. Emergency nurses' willingness to report errors decreased as the nurses' years of experience increased (r = -0.25, P = .03). Their willingness to report errors increased when they received more feedback about errors (r = 0.25, P = .03) and when their managers used a transactional leadership style (r = 0.28, P = .01). ED nurse managers can modify their leadership style to encourage error reporting. Timely feedback after an error report is particularly important. Engaging experienced nurses to understand error root causes could increase voluntary error reporting. Published by Elsevier Inc.

  14. Perceptions of species abundance, distribution, and diversity: Lessons from four decades of sampling on a government-managed reserve

    USGS Publications Warehouse

    Gibbons, J. Whitfield; Burke, Vincent J.; Lovich, Jefferey E.; Semlitsch, Raymond D.; Tuberville, Tracey D.; Bodie, J. Russell; Greene, Judith L.; Niewiarowski, Peter H.; Whiteman, Howard H.; Scott, David E.; Pechmann, Joseph H. K.; Harrison, Christopher R.; Bennett, Stephen H.; Krenz, John D.; Mills, Mark S.; Buhlmann, Kurt A.; Lee, John R.; Seigel, Richard A.; Tucker, Anton D.; Mills, Tony M.; Lamb, Trip; Dorcas, Michael E.; Congdon, Justin D.; Smith, Michael H.; Nelson, David H.; Dietsch, M. Barbara; Hanlin, Hugh G.; Ott, Jeannine A.; Karapatakis, Deno J.

    1997-01-01

    We examined data relative to species abundance, distribution, and diversity patterns of reptiles and amphibians to determine how perceptions change over time and with level of sampling effort. Location data were compiled on more than one million individual captures or observations of 98 species during a 44-year study period on the US Department of Energy’s (DOE) Savannah River Site National Environmental Research Park (SRS-NERP) in South Carolina. We suggest that perceptions of herpetofaunal species diversity are strongly dependent on level of effort and that land management decisions based on short-term data bases for some faunal groups could result in serious errors in environmental management. We provide evidence that acquiring information on biodiversity distribution patterns is compatible with multiyear spatially extensive research programs and also provide a perspective of what might be achieved if long-term, coordinated research efforts were instituted nationwide. To conduct biotic surveys on government-managed lands, we recommend revisions in the methods used by government agencies to acquire and report biodiversity data. We suggest that government and industry employees engaged in biodiversity survey efforts develop proficiency in field identification for one or more major taxonomic groups and be encouraged to measure the status of populations quantitatively with consistent and reliable methodologies. We also suggest that widespread academic cooperation in the dissemination of information on regional patterns of biodiversity could result by establishment of a peer-reviewed, scientifically rigorous journal concerned with status and trends of the biota of the United States.

  15. Physical Activity in Physical Education: Are Longer Lessons Better?

    PubMed Central

    Smith, Nicole J.; Monnat, Shannon M.; Lounsbery, Monica A.F.

    2015-01-01

    BACKGROUND The purpose of this study was to compare physical activity (PA) outcomes in a sample of high school physical education (PE) lessons from schools that adopted traditional versus modified block schedule formats. METHODS We used the System for Observing Fitness Instruction Time (SOFIT) to conduct observations of 168 high school (HS) PE lessons delivered by 22 PE teachers in 4 schools. We used t-tests and multilevel models were used to explore variability in moderate PA and vigorous PA. RESULTS PA outcomes were significantly different between modified block and traditional schools. Students who attended traditional schools engaged in more vigorous PA in PE lessons. Modified block lessons lost more scheduled lesson time due to poor transition to and from the locker room. PA outcomes were positively associated with fitness and teacher promotion of PA and negatively associated with lost time, class size, management, and knowledge. CONCLUSIONS Though PE proponents widely advocate for more PE minutes, this study showed that greater time scheduled in PE does not necessarily result in more student accrual of MVPA minutes. PMID:25611935

  16. A professional experience learning community for secondary mathematics: developing pre-service teachers' reflective practice

    NASA Astrophysics Data System (ADS)

    Cavanagh, Michael; McMaster, Heather

    2015-12-01

    This paper reports on the reflective practice of a group of nine secondary mathematics pre-service teachers. The pre-service teachers participated in a year-long, school-based professional experience program which focussed on observing, co-teaching and reflecting on a series of problem-solving lessons in two junior secondary school mathematics classrooms. The study used a mixed methods approach to consider the impact of shared pedagogical conversations on pre-service teachers' written reflections. It also examined whether there were differences in the focus of reflections depending on whether the lesson was taught by an experienced mathematics teacher, or taught by a pair of their peers, or co-taught by themselves with a peer. Results suggest that after participants have observed lessons taught by an experienced teacher and reflected collaboratively on those lessons, they continue to reflect on lessons taught by their peers and on their own lessons when co-teaching, rather than just describe or evaluate them. However, their written reflections across all contexts continued to focus primarily on teacher actions and classroom management rather than on student learning.

  17. Contribution of suppression difficulty and lessons learned in forecasting fire suppression operations productivity: A methodological approach

    Treesearch

    Francisco Rodríguez y Silva; Armando González-Cabán

    2016-01-01

    We propose an economic analysis using utility and productivity, and efficiency theories to provide fire managers a decision support tool to determine the most efficient fire management programs levels. By incorporating managers’ accumulated fire suppression experiences (capitalized experience) in the analysis we help fire managers...

  18. Writing syntheses for managers: Lessons from the Rainbow Series and Fire Effects Information System

    Treesearch

    Jane Kapler Smith; Kristin L. Zouhar; Janet Fryer

    2009-01-01

    Scientific knowledge is essential for sound wildland management, but this knowledge is a complex, ever-expanding resource. Managers often request syntheses or reviews of available knowledge, and scientists have responded with an increasing number of syntheses for managers. Unfortunately, little guidance is available for this kind of writing. While most scientists have...

  19. When global environmentalism meets local livelihoods: policy and management lessons

    Treesearch

    John Schelhas; Max J. Pfeffer

    2009-01-01

    Creation of national parks often imposes immediate livelihood costs on local people, and tensions between park managers and local people are common. Park managers have tried different approaches to managing relationships with local people, but nearly all include efforts to promote environmental values and behaviors. These efforts have had uneven results, and there is a...

  20. Professional Vision of Classroom Management and Learning Support in Science Classrooms--Does Professional Vision Differ across General and Content-Specific Classroom Interactions?

    ERIC Educational Resources Information Center

    Steffensky, Mirjam; Gold, Bernadette; Holdynski, Manfred; Möller, Kornelia

    2015-01-01

    The present study investigates the internal structure of professional vision of in-service teachers and student teachers with respect to classroom management and learning support in primary science lessons. Classroom management (including monitoring, managing momentum, and rules and routines) and learning support (including cognitive activation…

  1. Evaluating a Chronic Disease Management Improvement Collaboration: Lessons in Design and Implementation Fundamentals.

    PubMed

    Phillips, Kaye; Amar, Claudia; Elicksen-Jensen, Keesa

    2016-01-01

    For the Canadian Foundation for Healthcare Improvement (CFHI), the Atlantic Healthcare Collaboration (AHC) was a pivotal opportunity to build upon its experience and expertise in delivering regional change management training and to apply and refine its evaluation and performance measurement approach. This paper reports on its evaluation principles and approach, as well as the lessons learned as CFHI diligently coordinated and worked with improvement project (IP) teams and a network of stakeholders to design and undertake a suite of evaluative activities. The evaluation generated evidence and learnings about various elements of chronic disease prevention and management (CDPM) improvement processes, individual and team capacity building and the role and value of CFHI in facilitating tailored learning activities and networking among teams, coaches and other AHC stakeholders.

  2. Controlling changes - lessons learned from waste management facilities

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Johnson, B.M.; Koplow, A.S.; Stoll, F.E.

    This paper discusses lessons learned about change control at the Waste Reduction Operations Complex (WROC) and Waste Experimental Reduction Facility (WERF) of the Idaho National Engineering Laboratory (INEL). WROC and WERF have developed and implemented change control and an as-built drawing process and have identified structures, systems, and components (SSCS) for configuration management. The operations have also formed an Independent Review Committee to minimize costs and resources associated with changing documents. WROC and WERF perform waste management activities at the INEL. WROC activities include storage, treatment, and disposal of hazardous and mixed waste. WERF provides volume reduction of solid low-levelmore » waste through compaction, incineration, and sizing operations. WROC and WERF`s efforts aim to improve change control processes that have worked inefficiently in the past.« less

  3. Lessons Learned for Cx PRACA. Constellation Program Problem Reporting, Analysis and Corrective Action Process and System

    NASA Technical Reports Server (NTRS)

    Kelle, Pido I.; Ratterman, Christian; Gibbs, Cecil

    2009-01-01

    This slide presentation reviews the Constellation Program Problem Reporting, Analysis and Corrective Action Process and System (Cx PRACA). The goal of the Cx PRACA is to incorporate Lessons learned from the Shuttle, ISS, and Orbiter programs by creating a single tool for managing the PRACA process, that clearly defines the scope of PRACA applicability and what must be reported, and defines the ownership and responsibility for managing the PRACA process including disposition approval authority. CxP PRACA is a process, supported by a single information gathering data module which will be integrated with a single CxP Information System, providing interoperability, import and export capability making the CxP PRACA a more effective and user friendly technical and management tool.

  4. Small grant management in health and behavioral sciences: Lessons learned.

    PubMed

    Sakraida, Teresa J; D'Amico, Jessica; Thibault, Erica

    2010-08-01

    This article describes considerations in health and behavioral sciences small grant management and describes lessons learned during post-award implementation. Using the components by W. Sahlman [Sahlman, W. (1997). How to write a great business plan. Harvard Business Review, 75(4), 98-108] as a business framework, a plan was developed that included (a) building relationships with people in the research program and with external parties providing key resources, (b) establishing a perspective of opportunity for research advancement, (c) identifying the larger context of scientific culture and regulatory environment, and (d) anticipating problems with a flexible response and rewarding teamwork. Small grant management included developing a day-to-day system, building a grant/study program development plan, and initiating a marketing plan. Copyright 2010 Elsevier Inc. All rights reserved.

  5. Ballistic trauma: lessons learned from iraq and afghanistan.

    PubMed

    Shin, Emily H; Sabino, Jennifer M; Nanos, George P; Valerio, Ian L

    2015-02-01

    Management of upper extremity injuries secondary to ballistic and blast trauma can lead to challenging problems for the reconstructive surgeon. Given the recent conflicts in Iraq and Afghanistan, advancements in combat-casualty care, combined with a high-volume experience in the treatment of ballistic injuries, has led to continued advancements in the treatment of the severely injured upper extremity. There are several lessons learned that are translatable to civilian trauma centers and future conflicts. In this article, the authors provide an overview of the physics of ballistic injuries and principles in the management of such injuries through experience gained from military involvement in Iraq and Afghanistan.

  6. Ballistic Trauma: Lessons Learned from Iraq and Afghanistan

    PubMed Central

    Shin, Emily H.; Sabino, Jennifer M.; Nanos, George P.; Valerio, Ian L.

    2015-01-01

    Management of upper extremity injuries secondary to ballistic and blast trauma can lead to challenging problems for the reconstructive surgeon. Given the recent conflicts in Iraq and Afghanistan, advancements in combat-casualty care, combined with a high-volume experience in the treatment of ballistic injuries, has led to continued advancements in the treatment of the severely injured upper extremity. There are several lessons learned that are translatable to civilian trauma centers and future conflicts. In this article, the authors provide an overview of the physics of ballistic injuries and principles in the management of such injuries through experience gained from military involvement in Iraq and Afghanistan. PMID:25685099

  7. Learning Across Time Scales: Science, Policy, Management, and Communication

    NASA Astrophysics Data System (ADS)

    Stewart, M. M.

    2002-05-01

    This presentation will draw together common themes raised in the session and discuss lessons learned across time scales and their implications for managers and policy makers concerned with both climate change and variability. Session themes will be examined in the context of the upcoming World Summit on Sustainable Development (WSSD) and considered as opportunities for linking climate change policy discussions with lessons learned from the study of adaptation on seasonal to interannual time scales. The presentation will raise questions about future research directions, discuss recommendations for promoting learning across time scales, and explore options for better communicating the links between climate change and variability.

  8. STGT program: Ada coding and architecture lessons learned

    NASA Technical Reports Server (NTRS)

    Usavage, Paul; Nagurney, Don

    1992-01-01

    STGT (Second TDRSS Ground Terminal) is currently halfway through the System Integration Test phase (Level 4 Testing). To date, many software architecture and Ada language issues have been encountered and solved. This paper, which is the transcript of a presentation at the 3 Dec. meeting, attempts to define these lessons plus others learned regarding software project management and risk management issues, training, performance, reuse, and reliability. Observations are included regarding the use of particular Ada coding constructs, software architecture trade-offs during the prototyping, development and testing stages of the project, and dangers inherent in parallel or concurrent systems, software, hardware, and operations engineering.

  9. Evaluation of a school-based diabetes education intervention, an extension of Program ENERGY

    NASA Astrophysics Data System (ADS)

    Conner, Matthew David

    Background: The prevalence of both obesity and type 2 diabetes in the United States has increased over the past two decades and rates remain high. The latest data from the National Center for Health Statistics estimates that 36% of adults and 17% of children and adolescents in the US are obese (CDC Adult Obesity, CDC Childhood Obesity). Being overweight or obese greatly increases one's risk of developing several chronic diseases, such as type 2 diabetes. Approximately 8% of adults in the US have diabetes, type 2 diabetes accounts for 90-95% of these cases. Type 2 diabetes in children and adolescents is still rare, however clinical reports suggest an increase in the frequency of diagnosis (CDC Diabetes Fact Sheet, 2011). Results from the Diabetes Prevention Program show that the incidence of type 2 diabetes can be reduced through the adoption of a healthier lifestyle among high-risk individuals (DPP, 2002). Objectives: This classroom-based intervention included scientific coverage of energy balance, diabetes, diabetes prevention strategies, and diabetes management. Coverage of diabetes management topics were included in lesson content to further the students' understanding of the disease. Measurable short-term goals of the intervention included increases in: general diabetes knowledge, diabetes management knowledge, and awareness of type 2 diabetes prevention strategies. Methods: A total of 66 sixth grade students at Tavelli Elementary School in Fort Collins, CO completed the intervention. The program consisted of nine classroom-based lessons; students participated in one lesson every two weeks. The lessons were delivered from November of 2005 to May of 2006. Each bi-weekly lesson included a presentation and interactive group activities. Participants completed two diabetes knowledge questionnaires at baseline and post intervention. A diabetes survey developed by Program ENERGY measured general diabetes knowledge and awareness of type 2 diabetes prevention strategies. The second questionnaire, adapted from a survey developed for the Starr County Diabetes Education Study (Garcia et al, 2001), measured general diabetes and diabetes management knowledge. A comparison group, a total of 19 students, also completed both surveys during the study period. Results: Significant increases (p<0.05) were seen in the post-intervention study group in general diabetes knowledge, diabetes management knowledge, and awareness of diabetes prevention strategies, when compared to the baseline study group and comparison group.

  10. Leadership insights of the Chinese military classics for physician leaders and healthcare administrators.

    PubMed

    Enzenaue, Robert W

    2007-01-01

    Trite sayings from Chinese military classics often find their way into after-dinner fortune cookies in many Chinese restaurants in America. However, no one should underestimate the lessons from those Chinese military classics, and they certainly should never be trivialized. Leaders at all levels of healthcare management can learn timeless lessons spanning three millennia from the wisdom of ancient Chinese military writings.

  11. Computer Directed Training System (CDTS), User’s Manual

    DTIC Science & Technology

    1983-07-01

    lessons, together with an estimate of the time required for completion. a. BSCOl0. This lesson in BASIC ( Beginners All Purpose Symbolic Instruction Code...A2-8 FIGURESj Figure A2-1. Training Systems Manager and Training Monitors Responsibility Flowchart ...training at the site. Therefore, the TSM must be knowledgeable in the various tasks required. Figure A2-1 illustrates the position in the flowchart . These

  12. Let's Reduce and Recycle: Curriculum for Solid Waste Awareness. Lesson Plans for Grades K-6 and 7-12. Revised.

    ERIC Educational Resources Information Center

    Environmental Protection Agency, Washington, DC.

    The purpose of this guide is to educate young people about the problems associated with solid waste. The activities encourage them to think about options for reducing the amount of waste they generate and how they can help by recycling and learning about other waste management alternatives. The lesson plans deal specifically with garbage and…

  13. Transforming Effective Army Units: Best Practices and Lessons Learned

    DTIC Science & Technology

    2013-08-01

    Unlimited 106 Dorothy Young 703-545-2316 ii iii Technical Report 1326 Effective Army Units: Best Practices and Lessons Learned...SBCT units at Joint Base Lewis -McChord (JBLM), and two civilian subject matter experts on transformation from the Program Manager (PM) Stryker and...ISR Intelligence, Surveillance, Reconnaissance JBLM Joint Base Lewis -McChord JRTC Joint Readiness Training Center A-2 LNO Liaison

  14. Video Annotation Software Application for Thorough Collaborative Assessment of and Feedback on Microteaching Lessons in Geography Education

    ERIC Educational Resources Information Center

    van der Westhuizen, Christo P.; Golightly, Aubrey

    2015-01-01

    This article discusses the process and findings of a study in which video annotation (VideoANT) and a learning management system (LMS) were implemented together in the microteaching lessons of fourth-year geography student teachers. The aim was to ensure adequate assessment of and feedback for each student, since these aspects are, in general, a…

  15. Leaning in: lessons for leadership career development.

    PubMed

    Shirey, Maria R

    2013-11-01

    This department highlights change management strategies that may be successful in strategically planning and executing organizational change initiatives. With the goal of presenting practical approaches helpful to nurse leaders advancing organizational change, content includes evidence-based projects, tools, and resources that mobilize and sustain organizational change initiatives. In this article, the author introduces the book Lean In and presents applicable lessons for nursing leadership career development.

  16. How to Build a Robot: Collaborating to Strengthen STEM Programming in a Citywide System

    ERIC Educational Resources Information Center

    Groome, Meghan; Rodríguez, Linda M.

    2014-01-01

    You have to stick with it. It takes time, patience, trial and error, failure, and persistence. It is almost never perfect or finished, but, with a good team, you can build something that works. These are the lessons youth learn when building a robot, as many do in the out-of-school time (OST) programs supported by the initiative described in this…

  17. Managed access technology to combat contraband cell phones in prison: Findings from a process evaluation.

    PubMed

    Grommon, Eric

    2018-02-01

    Cell phones in correctional facilities have emerged as one of the most pervasive forms of modern contraband. This issue has been identified as a top priority for many correctional administrators in the United States. Managed access, a technology that utilizes cellular signals to capture transmissions from contraband phones, has received notable attention as a promising tool to combat this problem. However, this technology has received little evaluative attention. The present study offers a foundational process evaluation and draws upon output measures and stakeholder interviews to identify salient operational challenges and subsequent lessons learned about implementing and maintaining a managed access system. Findings suggest that while managed access captures large volumes of contraband cellular transmissions, the technology requires significant implementation planning, personnel support, and complex partnerships with commercial cellular carriers. Lessons learned provide guidance for practitioners to navigate these challenges and for scholars to improve future evaluations of managed access. Copyright © 2017 Elsevier Ltd. All rights reserved.

  18. Care coordination for children with special needs in Medicaid: lessons from Medicare.

    PubMed

    Stewart, Kate A; Bradley, Katharine W V; Zickafoose, Joseph S; Hildrich, Rachel; Ireys, Henry T; Brown, Randall S

    2018-04-01

    To provide actionable recommendations for improving care coordination programs for children with special healthcare needs (CSHCN) in Medicaid managed care.  Literature review and interviews with stakeholders and policy experts to adapt lessons learned from Medicare care coordination programs for CSHCN in Medicaid managed care. We reviewed syntheses of research on Medicare care coordination programs to identify lessons learned from successful programs. We adapted findings from Medicare to CSHCN in Medicaid based on an environmental scan and discussions with experts. The scan focused on Medicaid financing and eligibility for care coordination and how these intersect with Medicaid managed care. The expert discussions included pediatricians, Medicaid policy experts, Medicaid medical directors, and a former managed care executive, all experienced in care coordination for CSHCN. We found 6 elements that are consistently associated with improved outcomes from Medicare care coordination programs and relevant to CSHCN in Medicaid: 1) identifying and targeting high-risk patients, 2) clearly articulating what outcomes programs are likely to improve, 3) encouraging active engagement between care coordinators and primary care providers, 4) requiring some in-person contact between care coordinators and patients, 5) facilitating information sharing among providers, and 6) supplementing care coordinators' expertise with that of other clinical experts. States and Medicaid managed care organizations have many options for designing effective care coordination programs for CSHCN. Their choices should account for the diversity of conditions among CSHCN, families' capacity to coordinate care, and social determinants of health.

  19. Sustainability Through Technology Licensing and Commercialization: Lessons Learned from the TRIAD Project

    PubMed Central

    Payne, Philip R.O.

    2014-01-01

    Ongoing transformation relative to the funding climate for healthcare research programs housed in academic and non-profit research organizations has led to a new (or renewed) emphasis on the pursuit of non-traditional sustainability models. This need is often particularly acute in the context of data management and sharing infrastructure that is developed under the auspices of such research initiatives. One option for achieving sustainability of such data management and sharing infrastructure is the pursuit of technology licensing and commercialization, in an effort to establish public-private or equivalent partnerships that sustain and even expand upon the development and dissemination of research-oriented data management and sharing technologies. However, the critical success factors for technology licensing and commercialization efforts are often unknown to individuals outside of the private sector, thus making this type of endeavor challenging to investigators in academic and non-profit settings. In response to such a gap in knowledge, this article will review a number of generalizable lessons learned from an effort undertaken at The Ohio State University to commercialize a prototypical research-oriented data management and sharing infrastructure, known as the Translational Research Informatics and Data Management (TRIAD) Grid. It is important to note that the specific emphasis of these lessons learned is on the early stages of moving a technology from the research setting into a private-sector entity and as such are particularly relevant to academic investigators interested in pursuing such activities. PMID:25848609

  20. The National Trauma Institute: Lessons learned in the funding and conduct of 16 trauma research studies.

    PubMed

    Price, Michelle A; Beilman, Gregory J; Fabian, Timothy C; Hoyt, David B; Jurkovich, Gregory J; Knudson, M Margaret; MacKenzie, Ellen J; Marshall, Vivienne S; Overton, Kimberly E; Peitzman, Andrew B; Phillips, Monica J; Pruitt, Basil A; Smith, Sharon L; Stewart, Ronald M; Jenkins, Donald H

    2016-09-01

    To increase trauma-related research and elevate trauma on the national research agenda, the National Trauma Institute (NTI) issued calls for proposals, selected funding recipients, and coordinated 16 federally funded (Department of Defense) trauma research awards over a 4-year period. We sought to collect and describe the lessons learned from this activity to inform future researchers of barriers and facilitators. Fifteen principal investigators participated in semistructured interviews focused on study management issues such as securing institutional approvals, screening and enrollment, multisite trials management, project funding, staffing, and institutional support. NTI Science Committee meeting minutes and study management data were included in the analysis. Simple descriptive statistics were generated and textual data were analyzed for common themes. Principal investigators reported challenges in obtaining institutional approvals, delays in study initiation, screening and enrollment, multisite management, and study funding. Most were able to successfully resolve challenges and have been productive in terms of scholarly publications, securing additional research funding, and training future trauma investigators. Lessons learned in the conduct of the first two funding rounds managed by NTI are instructive in four key areas: regulatory processes, multisite coordination, adequate funding, and the importance of an established research infrastructure to ensure study success. Recommendations for addressing institution-related and investigator-related challenges are discussed along with ongoing advocacy efforts to secure sustained federal funding of a national trauma research program commensurate with the burden of injury.

  1. Error detection and reduction in blood banking.

    PubMed

    Motschman, T L; Moore, S B

    1996-12-01

    Error management plays a major role in facility process improvement efforts. By detecting and reducing errors, quality and, therefore, patient care improve. It begins with a strong organizational foundation of management attitude with clear, consistent employee direction and appropriate physical facilities. Clearly defined critical processes, critical activities, and SOPs act as the framework for operations as well as active quality monitoring. To assure that personnel can detect an report errors they must be trained in both operational duties and error management practices. Use of simulated/intentional errors and incorporation of error detection into competency assessment keeps employees practiced, confident, and diminishes fear of the unknown. Personnel can clearly see that errors are indeed used as opportunities for process improvement and not for punishment. The facility must have a clearly defined and consistently used definition for reportable errors. Reportable errors should include those errors with potentially harmful outcomes as well as those errors that are "upstream," and thus further away from the outcome. A well-written error report consists of who, what, when, where, why/how, and follow-up to the error. Before correction can occur, an investigation to determine the underlying cause of the error should be undertaken. Obviously, the best corrective action is prevention. Correction can occur at five different levels; however, only three of these levels are directed at prevention. Prevention requires a method to collect and analyze data concerning errors. In the authors' facility a functional error classification method and a quality system-based classification have been useful. An active method to search for problems uncovers them further upstream, before they can have disastrous outcomes. In the continual quest for improving processes, an error management program is itself a process that needs improvement, and we must strive to always close the circle of quality assurance. Ultimately, the goal of better patient care will be the reward.

  2. Perceptions of Species Abundance, Distribution, and Diversity:Lessons from Four Decades of Sampling on a Government-Managed Reserve

    PubMed

    Gibbons; Burke; Lovich; Semlitsch; Tuberville; Bodie; Greene; Niewiarowski; Whiteman; Scott; Pechmann; Harrison; Bennett; Krenz; Mills; Buhlmann; Lee; Seigel; Tucker; Mills; Lamb; Dorcas; Congdon; Smith; Nelson; Dietsch; Hanlin; Ott; Karapatakis

    1997-03-01

    / We examined data relative to species abundance, distribution, anddiversity patterns of reptiles and amphibians to determine how perceptionschange over time and with level of sampling effort. Location data werecompiled on more than one million individual captures or observations of 98species during a 44-year study period on the US Department of Energy's(DOE) Savannah River Site National Environmental Research Park (SRS-NERP) inSouth Carolina. We suggest that perceptions of herpetofaunal speciesdiversity are strongly dependent on level of effort and that land managementdecisions based on short-term data bases for some faunal groups could resultin serious errors in environmental management. We provide evidence thatacquiring information on biodiversity distribution patterns is compatiblewith multiyear spatially extensive research programs and also provide aperspective of what might be achieved if long-term, coordinated researchefforts were instituted nationwide.To conduct biotic surveys on government-managed lands, we recommend revisionsin the methods used by government agencies to acquire and report biodiversitydata. We suggest that government and industry employees engaged inbiodiversity survey efforts develop proficiency in field identification forone or more major taxonomic groups and be encouraged to measure the status ofpopulations quantitatively with consistent and reliable methodologies. Wealso suggest that widespread academic cooperation in the dissemination ofinformation on regional patterns of biodiversity could result byestablishment of a peer-reviewed, scientifically rigorous journal concernedwith status and trends of the biota of the United States. KEY WORDS: Abundance; Amphibian; Biodiversity; Distribution; Landmanagement; Reptile

  3. Issues in NASA program and project management

    NASA Technical Reports Server (NTRS)

    Hoban, Francis T. (Editor)

    1990-01-01

    This volume is the third in an ongoing series on aerospace project management at NASA. Articles in this volume cover the attitude of the program manager, program control and performance measurement, risk management, cost plus award fee contracting, lessons learned from the development of the Far Infrared Absolute Spectrometer (FIRAS), small projects management, and age distribution of NASA scientists and engineers. A section on resources for NASA managers rounds out the publication.

  4. Issues in NASA program and project management

    NASA Technical Reports Server (NTRS)

    Hoban, Francis T. (Editor)

    1991-01-01

    This volume is the third in an ongoing series on aerospace project management at NASA. Articles in this volume cover the attitude of the program manager, program control and performance measurement, risk management, cost plus award fee contracting, lessons learned from the development of the Far Infrared Absolute Spectrometer (FIRAS), small projects management, and age distribution of NASA scientists and engineers. A section on resources for NASA managers rounds out the publication.

  5. TH-B-BRC-00: How to Identify and Resolve Potential Clinical Errors Before They Impact Patients Treatment: Lessons Learned

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    NONE

    2016-06-15

    Radiation treatment consists of a chain of events influenced by the quality of machine operation, beam data commissioning, machine calibration, patient specific data, simulation, treatment planning, imaging and treatment delivery. There is always a chance that the clinical medical physicist may make or fail to detect an error in one of the events that may impact on the patient’s treatment. In the clinical scenario, errors may be systematic and, without peer review, may have a low detectability because they are not part of routine QA procedures. During treatment, there might be errors on machine that needs attention. External reviews ofmore » some of the treatment delivery components by independent reviewers, like IROC, can detect errors, but may not be timely. The goal of this session is to help junior clinical physicists identify potential errors as well as the approach of quality assurance to perform a root cause analysis to find and eliminate an error and to continually monitor for errors. A compilation of potential errors will be presented by examples of the thought process required to spot the error and determine the root cause. Examples may include unusual machine operation, erratic electrometer reading, consistent lower electron output, variation in photon output, body parts inadvertently left in beam, unusual treatment plan, poor normalization, hot spots etc. Awareness of the possibility and detection of error in any link of the treatment process chain will help improve the safe and accurate delivery of radiation to patients. Four experts will discuss how to identify errors in four areas of clinical treatment. D. Followill, NIH grant CA 180803.« less

  6. Total Quality Management: Getting Started

    DTIC Science & Technology

    1990-08-01

    Quality Management (TQM) program using Organizational Development (OD) intervention techniques to gain acceptance of the program. It emphasizes human behavior and the need for collaborative management and consensus in organizational change. Lessons learned stress the importance of choosing a skilled TQM facilitator, training process action teams, and fostering open communication and teamwork to minimize resistance to change. Keywords: Management planning and control, Quality control, Quality , Management , Organization change, Organization development,

  7. Container Management During Desert Shield/Storm: An Analysis and Critique of Lessons Learned

    DTIC Science & Technology

    1993-04-15

    across the distribution spectrum.14 These issues were grouped into five major categories: Containerization and Packaging, Distribution Management , Automation...of containers is needed, according to TDAP. Distribution - Management issues. The Desert Shield experience identified three general distribution ...recommended the formation of a 19 Theater Distribution Management Center from the assets of the Movement Control Agency (MCA) and Material Management

  8. Ideologies of aid, practices of power: lessons for Medicaid managed care.

    PubMed

    Nelson, Nancy L

    2005-03-01

    The articles in this special issue teach valuable lessons based on what happened in New Mexico with the shift to Medicaid managed care. By reframing these lessons in broader historical and cultural terms with reference to aid programs, we have the opportunity to learn a great deal more about the relationship between poverty, public policy, and ideology. Medicaid as a state and federal aid program in the United States and economic development programs as foreign aid provide useful analogies specifically because they exhibit a variety of parallel patterns. The increasing concatenation of corporate interests with state and nongovernmental interests in aid programs is ultimately producing a less centralized system of power and responsibility. This process of decentralization, however, is not undermining the sources of power behind aid efforts, although it does make the connections between intent, planning, and outcome less direct. Ultimately, the devolution of power produces many unintended consequences for aid policy. But it also reinforces the perspective that aid and the need for it are nonpolitical issues.

  9. Lunar Prospector: First Results and Lessons Learned

    NASA Astrophysics Data System (ADS)

    Scott Hubbard, G.; Feldman, William; Cox, Sylvia A.; Smith, Marcie A.; Chu-Thielbar, Lisa

    2002-01-01

    Lunar Prospector, the first competitively selected mission in NASA's Discovery Program, is conducting a one-year orbital survey of the Moon's composition and structure. Launched on January 6 1998, the suite of five instruments is measuring water/ice to a sensitivity of 50 ppm (hydrogen), detecting key elemental constituents, gas release events and mapping the Moon's gravitational and magnetic fields. The mission is described with emphasis on the first scientific results and lessons learned from managing a very low cost project. A mission overview and systems description is given along with final mission trajectories. Lessons learned from government-industry teaming, new modes of project management, and novel contractual arrangements are discussed. The suite of five instruments (neutron spectrometer, alpha particle spectrometer, gamma-ray spectrometer, electron reflectometer and magnetometer) is outlined with attention to final technical performance as well as development on a constrained budget and schedule. A review of our novel approaches to education and public outreach is discussed and a summary with suggestions and implications for future missions is provided.

  10. Surgical and Resuscitation Capabilities for the "Next War" Based on Lessons Learned From "This War".

    PubMed

    Freel, David; Warr, Bradley J

    2016-01-01

    The Army gleaned many lessons regarding the provision of medical care to casualties during the past 14 years of combat. Using these lessons learned in the Joint Capabilities and Integration Development process and through the analysis of an integrated process action team, the Army recently approved 3 changes to medical organizations that are intended to provide trauma management farther forward on the battlefield. These changes include the substitution of an emergency medicine trained physician and emergency medicine physician assistant (PA) in lieu of a general medical officer and primary care PA within the brigade combat team; reorganization of the forward surgical team into a forward surgical and resuscitative team; and the modularization of the traditional 248 bed combat support hospital. The Army anticipates that these changes related to personnel, organizations, doctrine, and materiel will enable Army medicine to provide enhanced trauma management closer to the point of a combatant's injury. These modifications are projected to begin in fiscal year 2016.

  11. LESSONS LEARNED IN OPERATING THE HOSE-IN-HOSE SYSTEM FOR TRANSFSERRING SLUDGE AT HANFORDS K-BASINS

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    PERES MW

    In May 2007, the Department of Energy and the Fluor Hanford K Basin Closure Project completed transferring sludge from the K East Basin to new containers in the K West Basin using a Hose-in-Hose system. This project presented a number of complex and unique technical, operational, and management challenges that had to be resolved to complete the required transfers and satisfy project milestones. The project team (including DOE; regulators; and Fluor management, operations, maintenance, engineering and all other support organizations) found innovative solutions to each challenge. This paper records lessons learned during the operational phase of the sludge transfer viamore » the Hose-In-Hose system. The subject is limited to the operational phase and does not cover design, development, testing or turnover. A discussion of the situation or problem encountered is provided, along with the lesson learned as applicable to a future program or project.« less

  12. Demand Forecasting: An Evaluation of DODs Accuracy Metric and Navys Procedures

    DTIC Science & Technology

    2016-06-01

    inventory management improvement plan, mean of absolute scaled error, lead time adjusted squared error, forecast accuracy, benchmarking, naïve method...Manager JASA Journal of the American Statistical Association LASE Lead-time Adjusted Squared Error LCI Life Cycle Indicator MA Moving Average MAE...Mean Squared Error xvi NAVSUP Naval Supply Systems Command NDAA National Defense Authorization Act NIIN National Individual Identification Number

  13. How Students View the Boundaries Between Their Science and Religious Education Concerning the Origins of Life and the Universe

    PubMed Central

    BROCK, RICHARD; TABER, KEITH S.; RIGA, FRAN

    2016-01-01

    ABSTRACT Internationally in secondary schools, lessons are typically taught by subject specialists, raising the question of how to accommodate teaching which bridges the sciences and humanities. This is the first study to look at how students make sense of the teaching they receive in two subjects (science and religious education [RE]) when one subject's curriculum explicitly refers to cross‐disciplinary study and the other does not. Interviews with 61 students in seven schools in England suggested that students perceive a permeable boundary between science and their learning in science lessons and also a permeable boundary between religion and their learning in RE lessons, yet perceive a firm boundary between science lessons and RE lessons. We concluded that it is unreasonable to expect students to transfer instruction about cross‐disciplinary perspectives across such impermeable subject boundaries. Finally, we consider the implications of these findings for the successful management of cross‐disciplinary education. PMID:27812226

  14. How Students View the Boundaries Between Their Science and Religious Education Concerning the Origins of Life and the Universe.

    PubMed

    Billingsley, Berry; Brock, Richard; Taber, Keith S; Riga, Fran

    2016-05-01

    Internationally in secondary schools, lessons are typically taught by subject specialists, raising the question of how to accommodate teaching which bridges the sciences and humanities. This is the first study to look at how students make sense of the teaching they receive in two subjects (science and religious education [RE]) when one subject's curriculum explicitly refers to cross-disciplinary study and the other does not. Interviews with 61 students in seven schools in England suggested that students perceive a permeable boundary between science and their learning in science lessons and also a permeable boundary between religion and their learning in RE lessons, yet perceive a firm boundary between science lessons and RE lessons. We concluded that it is unreasonable to expect students to transfer instruction about cross-disciplinary perspectives across such impermeable subject boundaries. Finally, we consider the implications of these findings for the successful management of cross-disciplinary education.

  15. Aspirations and common tensions: larger lessons from the third US national climate assessment

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Moser, Susanne C.; Melillo, Jerry M.; Jacobs, Katharine L.

    2015-10-21

    The Third US National Climate Assessment (NCA3) was produced by experts in response to the US Global Change Research Act of 1990. Based on lessons learned from previous domestic and international assessments, the NCA3 was designed to speak to a broad public and inform the concerns of policy- and decision-makers at different scales. The NCA3 was also intended to be the first step in an ongoing assessment process that would build the nation’s capacity to respond to climate change. This concluding paper draws larger lessons from the insights gained throughout the assessment process that are of significance to future USmore » and international assessment designers. We bring attention to process and products delivered, communication and engagement efforts, and how they contributed to the sustained assessment. Based on areas where expectations were exceeded or not fully met, we address four common tensions that all assessment designers must confront and manage: between (1) core assessment ingredients (knowledge base, institutional set-up, principled process, and the people involved), (2) national scope and subnational adaptive management information needs, (3) scope, complexity, and manageability, and (4) deliberate evaluation and ongoing learning approaches. Managing these tensions, amidst the social and political contexts in which assessments are conducted, is critical to ensure that assessments are feasible and productive, while its outcomes are perceived as credible, salient, and legitimate.« less

  16. Sharing lessons learned and best practices in deactivation and decommissioning techniques among U.S. Department of Energy contractors

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Lackey, Michael B.; Waisley, Sandra L.; Dusek, Lansing G.

    2007-07-01

    Approximately $153.2 billion of work currently remains in the United States Department of Energy's (DOE's) Office of Environmental Management (EM) life cycle budget for United States projects. Contractors who manage facilities for the DOE have been challenged to identify transformational changes to reduce the life cycle costs and develop a knowledge management system that identifies, disseminates, and tracks the implementation of lessons learned and best practices. At the request of the DOE's EM Office of Engineering and Technology, the Energy Facility Contractors Group (EFCOG) responded to the challenge with formation of the Deactivation and Decommissioning (D and D) and Facilitymore » Engineering (DD/FE) Working Group. Since October 2006, members have already made significant progress in realizing their goals: adding new D and D best practices to the existing EFCOG Best Practices database; participating in lessons learned forums; and contributing to a DOE initiative on identifying technology needs. The group is also participating in a DOE project management initiative to develop implementation guidelines, as well as a DOE radiation protection initiative to institute a more predictable and standardized approach to approving authorized limits and independently verifying cleanup completion at EM sites. Finally, a D and D hotline to provide real-time solutions to D and D challenges is also being launched. (authors)« less

  17. Assessment of Understanding: Student Teachers' Preparation, Implementation and Reflection of a Lesson Plan for Science

    NASA Astrophysics Data System (ADS)

    Juhler, Martin Vogt

    2018-06-01

    Research finds that student teachers often fail to make observable instructional goals, without which a secure bridge between instruction and assessment is precluded. This is one reason that recent reports state that teacher education needs to become better at helping student teachers to develop their thinking about and skills in assessing pupils' learning. Currently in Europe, the Lesson Study method and the Content Representation tool, which both have a specific focus on assessment, have started to address this problem. This article describes and discusses an intervention in which Lesson Study was used in combination with Content Representation in student teachers' field practice. Empirical materials from one group of student teachers were analyzed to illustrate how the student teachers worked with assessment during the planning of a lesson, how they implemented it in a research lesson, and how they used the gathered observations to make claims about assessment aims. The findings suggest that the student teachers placed greater emphasis on assessment through the intervention. However, it is also found that more attention should have been dedicated to the planning phase and that the group did not manage to keep a research focus throughout the Lesson Study process. This suggests that it properly would be beneficial with several planning sessions prior to the research lesson, as well as having an expert teacher leading the Lesson Study.

  18. Assessment of Understanding: Student Teachers' Preparation, Implementation and Reflection of a Lesson Plan for Science

    NASA Astrophysics Data System (ADS)

    Juhler, Martin Vogt

    2017-05-01

    Research finds that student teachers often fail to make observable instructional goals, without which a secure bridge between instruction and assessment is precluded. This is one reason that recent reports state that teacher education needs to become better at helping student teachers to develop their thinking about and skills in assessing pupils' learning. Currently in Europe, the Lesson Study method and the Content Representation tool, which both have a specific focus on assessment, have started to address this problem. This article describes and discusses an intervention in which Lesson Study was used in combination with Content Representation in student teachers' field practice. Empirical materials from one group of student teachers were analyzed to illustrate how the student teachers worked with assessment during the planning of a lesson, how they implemented it in a research lesson, and how they used the gathered observations to make claims about assessment aims. The findings suggest that the student teachers placed greater emphasis on assessment through the intervention. However, it is also found that more attention should have been dedicated to the planning phase and that the group did not manage to keep a research focus throughout the Lesson Study process. This suggests that it properly would be beneficial with several planning sessions prior to the research lesson, as well as having an expert teacher leading the Lesson Study.

  19. The Campus Environmental Management System Cycle in Practice: 15 Years of Environmental Management, Education and Research at Dalhousie University

    ERIC Educational Resources Information Center

    Clarke, Amelia

    2006-01-01

    Purpose: To challenge the deliberate strategy approach of the environmental management system (EMS) cycle, and offer a model based on both the practical reality experienced at Dalhousie University and emergent strategy theory. Also, to share some of the lessons learned in the 15 years of environmental management at Dalhousie University.…

  20. Variable density management in riparian reserves: lessons learned from an operational study in managed forests of western Oregon, USA.

    Treesearch

    Samuel Chan; Paul Anderson; John Cissel; Larry Lateen; Charley Thompson

    2004-01-01

    A large-scale operational study has been undertaken to investigate variable density management in conjunction with riparian buffers as a means to accelerate development of late-seral habitat, facilitate rare species management, and maintain riparian functions in 40-70 year-old headwater forests in western Oregon, USA. Upland variable retention treatments include...

  1. Mississippi Curriculum Framework for Child Care and Guidance Management and Services (Program CIP: 20.0201--Child Care & Guidance Workers and Managers). Secondary Programs.

    ERIC Educational Resources Information Center

    Mississippi Research and Curriculum Unit for Vocational and Technical Education, State College.

    This document, which reflects Mississippi's statutory requirement that instructional programs be based on core curricula and performance-based assessment, contains outlines of the instructional units required in local instructional management plans and daily lesson plans for child care and guidance management and services I and II. Presented first…

  2. ENTEL: A Case Study on Knowledge Networks and the Impact of Web 2.0 Technologies

    ERIC Educational Resources Information Center

    Griffiths, Paul; Arenas, Teresita

    2014-01-01

    This study re-visits an organisation that defined its knowledge-management strategy in 2008-9 applying an established strategy-intellectual capital alignment framework. It addresses questions "How has knowledge management evolved at ENTEL, and what lessons can be learnt? Does the strategy-knowledge management alignment framework applied at…

  3. Nonprofit Management Education in MPA Programs: Lessons for Successful Track Building

    ERIC Educational Resources Information Center

    Gerlach, John David

    2016-01-01

    As the American nonprofit sector continues to grow, so does interest in nonprofit management graduate education. MPA programs play a significant role in preparing students for work in the nonprofit field. This article examines nonprofit management as an area of graduate study, paying particular attention to how NASPAA-accredited MPA programs…

  4. Cogenerating a Competency-based HRM Degree: A Model and Some Lessons from Experience.

    ERIC Educational Resources Information Center

    Wooten, Kevin C.; Elden, Max

    2001-01-01

    A competency-based degree program in human resource management was co-generated by six groups of stakeholders who synthesized competency models using group decision support software. The program focuses on core human resource processes, general business management, strategic decision making and problem solving, change management, and personal…

  5. Cyclone Tracy and the Darwin Educators: A Case in Crisis Management.

    ERIC Educational Resources Information Center

    Beare, Hedley

    The story of successful crisis management teaches some lessons applicable not only to surmounting crises but to everyday management decisions as well. On Christmas eve, 1974, a cyclone demolished 90 percent of the city of Darwin in Australia's Northern Territory. As thousands gathered in neighborhood schools, a team of educational administrators…

  6. Elements of a Knowledge Management Guide for Public Sector Organizations

    ERIC Educational Resources Information Center

    Harris, Mark Cameron

    2013-01-01

    This study explored the factors that are critical to the success of public (government) sector knowledge management initiatives and the lessons from private sector knowledge management and organizational learning that apply in the public sector. The goal was to create a concise guide, based on research-validated success factors, to aid government…

  7. Seeking Information after the 2010 Haiti Earthquake: A Case Study in Mass-Fatality Management

    ERIC Educational Resources Information Center

    Gupta, Kailash

    2013-01-01

    The 2010 earthquake in Haiti, which killed an estimated 316,000 people, offered many lessons in mass-fatality management (MFM). The dissertation defined MFM in seeking information and in recovery, preservation, identification, and disposition of human remains. Specifically, it examined how mass fatalities were managed in Haiti, how affected…

  8. An uneven-aged management strategy: lessons learned

    Treesearch

    Mark T. Smith; John D. Exline

    2002-01-01

    Use of an ecosystem approach at a landscape scale to program and guide accomplishments of multi-resource and social objectives has been discussed between researchers and natural resource managers for many years. Presently, great interest exists in the applicability of uneven-aged management practices for such an approach in conifer forests of the Sierra Nevada of...

  9. Classroom Management in the Social Studies Class. How to Do It Series, Series 2, No. 7.

    ERIC Educational Resources Information Center

    Sullivan, Cheryl Granade

    Classroom management is discussed in terms of effective instruction, successful group management, maximum use of space, time, and resources, meaningful discipline, student rights, and change strategies. The discussion of effective instruction stresses appropriateness, completeness, clarity, and a variety of lessons. Techniques for successful group…

  10. Hunting and Wildlife Management. Issue Pac.

    ERIC Educational Resources Information Center

    Fish and Wildlife Service (Dept. of Interior), Washington, DC.

    The materials in this educational packet are designed for use with students in grades 4 through 7. They consist of an overview, three lesson plans, student data sheets, and a poster. The overview discusses hunting as a tool for wildlife management, the management of wildlife populations and hunter participation in providing research data, and the…

  11. "My Lesson Plan Was Perfect Until I Tried to Teach": Care Ethics into Practice in Classroom Management

    ERIC Educational Resources Information Center

    Rabin, Colette; Smith, Grinell

    2016-01-01

    As teacher educators, the authors developed an assignment focused on care ethics to prepare teacher candidates to design classroom-management procedures aimed at cultivating caring community. The teacher candidates revised traditional classroom-management processes, such as class rules, into cocreated norms. They also designed original management…

  12. Analysis of Risk Management in Adapted Physical Education Textbooks

    ERIC Educational Resources Information Center

    Murphy, Kelle L.; Donovan, Jacqueline B.; Berg, Dominck A.

    2016-01-01

    Physical education teacher education (PETE) programs vary on how the topics of safe teaching and risk management are addressed. Common practices to cover such issues include requiring textbooks, lesson planning, peer teaching, videotaping, reflecting, and reading case law analyses. We used a mixed methods design to examine how risk management is…

  13. Medical informatics education needs information system practicums in health care settings--experiences and lessons learned from 32 practicums at four universities in two countries.

    PubMed

    Haux, R; Ammenwerth, E; Häber, A; Hübner-Bloder, G; Knaup-Gregori, P; Lechleitner, G; Leiner, F; Weber, R; Winter, A; Wolff, A C

    2006-01-01

    To report about the themes and about experiences with practicums in the management of information systems in health care settings (health information management) for medical informatics students. We first summarize the topics of the health information management practicums/projects that the authors organized between 1990 and 2003 for the medical informatics programs at Heidelberg/Heilbronn, Germany, UMIT, Austria, as well as for the informatics program at the University of Leipzig, Germany. Experiences and lessons learned, obtained from the faculty that organized the practicums in the past 14 years, are reported. Thirty (of 32) health information management practicums focused on the analysis of health information systems. These took place inside university medical centers. Although the practicums were time-intensive and required intensively tutoring students with regard to health information management and project management, feedback from the students and graduates was mainly positive. It is clearly recommended that students specializing in medical informatics need to be confronted with real-world problems of health information systems during their studies.

  14. German experience in managing stormwater with green infrastructure

    EPA Science Inventory

    This paper identifies and describes experience with ‘green’ stormwater management practices in Germany. It provides the context in which developments took place and extracts lessons learned to inform efforts of other countries in confronting urban stormwater challenges. Our findi...

  15. Integrated corridor management : implementation guide and lessons learned (final report version 2.0).

    DOT National Transportation Integrated Search

    2015-09-01

    This implementation guide is intended for use by adopters of integrated corridor management (ICM) approaches and strategies to address congestion and travel time reliability issues within specific travel corridors. It introduces the topic of ICM and ...

  16. Connection Development: Web Lessons from Westchester.

    ERIC Educational Resources Information Center

    Freedman, Maurice J.

    1996-01-01

    Committed to utilizing information technology, the Westchester Library System (New York) made the World Wide Web publicly accessible. Describes the planning, implementation, and management process; obstacles involving financing; establishing Internet connectivity; and vendor negotiations. Westchester hired a Web manager, created Internet use…

  17. Integrated corridor management analysis, modeling, and simulation results for the test corridor.

    DOT National Transportation Integrated Search

    2008-06-01

    This report documents the Integrated Corridor Management (ICM) Analysis Modeling and Simulation (AMS) tools and strategies used on a Test Corridor, presents results and lessons-learned, and documents the relative capability of AMS to support benefit-...

  18. Flight deck disturbance management: a simulator study of diagnosis and recovery from breakdowns in pilot-automation coordination.

    PubMed

    Nikolic, Mark I; Sarter, Nadine B

    2007-08-01

    To examine operator strategies for diagnosing and recovering from errors and disturbances as well as the impact of automation design and time pressure on these processes. Considerable efforts have been directed at error prevention through training and design. However, because errors cannot be eliminated completely, their detection, diagnosis, and recovery must also be supported. Research has focused almost exclusively on error detection. Little is known about error diagnosis and recovery, especially in the context of event-driven tasks and domains. With a confederate pilot, 12 airline pilots flew a 1-hr simulator scenario that involved three challenging automation-related tasks and events that were likely to produce erroneous actions or assessments. Behavioral data were compared with a canonical path to examine pilots' error and disturbance management strategies. Debriefings were conducted to probe pilots' system knowledge. Pilots seldom followed the canonical path to cope with the scenario events. Detection of a disturbance was often delayed. Diagnostic episodes were rare because of pilots' knowledge gaps and time criticality. In many cases, generic inefficient recovery strategies were observed, and pilots relied on high levels of automation to manage the consequences of an error. Our findings describe and explain the nature and shortcomings of pilots' error management activities. They highlight the need for improved automation training and design to achieve more timely detection, accurate explanation, and effective recovery from errors and disturbances. Our findings can inform the design of tools and techniques that support disturbance management in various complex, event-driven environments.

  19. Defense Management: DOD’s Conference Policy Is Generally Consistent with OMB’s Requirements

    DTIC Science & Technology

    2014-01-01

    of conference costs and updated it in November 2013, citing lessons learned from implementing the September 2012 policy, among other things. The...memorandum accompanying the November 2013 policy, updates were based upon lessons learned from implementation of the September 2012 policy, the budget...higher learning or professional licensure or certification, or other training entities. However, events are not exempt simply because they offer

  20. Managing Differences in Stakeholder Relationships and Organizational Cultures in E-Learning Development: Lessons from the UK eUniversity Experience

    ERIC Educational Resources Information Center

    Conole, Grainne; Carusi, Annamaria; de Laat, Maarten; Wilcox, Pauline; Darby, Jonathan

    2006-01-01

    This paper presents some of the initial findings of a series of studies documenting the UK eUniversity (UKeU) approach to and experience of e-learning. It will focus on the experiences and lessons learned of members of the learning technology team within the UKeU or people working closely with them. Our particular interest is to describe the…

  1. Analysis of Base Services Structure and Development of Cost-Saving Strategies to Counterattack Decreasing Funding Levels

    DTIC Science & Technology

    2005-12-01

    7 habits of highly effective people ” puts it this way: “People and their managers are...corporations and 86 Covey, Stephen R., 7 Habits of Highly Effective People : Powerful Lessons in Personal Change, Simon Schuster, 1989, p. 52. 68...levels from January to July, 2006. Covey, Stephen R., 7 Habits of Highly Effective People : Powerful Lessons in Personal Change,

  2. Designing and implementing a balanced scorecard: lessons learned in nonprofit implementation.

    PubMed

    Gumbus, Andra; Wilson, Tom

    2004-01-01

    The balanced scorecard has been referred to as the management innovation of the century, and extensive articles have been written using case studies of organizations that use this performance measurement system. This article addresses the key issues of design and implementation with a step-by-step guide to how to design a balanced scorecard and lessons to avoid implementation problems in government and nonprofit settings.

  3. WHY CAN'T WE LEARN FROM OUR MISTAKES LEARN THE LESSON TELL THE STORY

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    LANGSTAFF, D.C.

    2005-02-03

    Tell the story well and people can learn from the lesson. The United States Department of Energy (DOE) Office of Environmental Management (EM) and its contractors are pursuing environmental remediation at the Hanford Site. This endeavor has been underway for a number of years, both at Hanford and at other sites across the DOE complex. Independently, the occurrence of two fatalities on two Sites at opposite ends of the country within two weeks raised the question, ''What is going on in the Field?'' Corporate EM management communicated directly with Field Office Managers to answer the question. As a result ofmore » this intense interest and focused communication, EM identified four areas that need additional exploration. One of those is, ''EM's ability to learn from its mistakes.'' The need to cultivate the ability to learn from our mistakes is not unique to DOE. A quick review of EM Lessons Learned reports shows that most of the reports in the EM system originate at the sites with the largest budgets doing the most work. A second look, however, reveals that many reports are repetitive, that many people might consider many reports trivial, and that reports on some of the more significant events sometimes take a long time to get distributed across the DOE Complex. Spot checks of event reports revealed frequent identification of symptoms rather than root causes. With a high percentage of identified root causes in the questionable category, it is highly unlikely that the real root causes of many events are being corrected, thus leading to recurrences of events. To learn the lesson from an event, people need to be aware of the root causes of the event. Someone has to tell a story the reader can learn from, i.e., include all the information needed to understand what happened and why it happened. Most importantly, they need to understand the lesson to be learned.« less

  4. Introducing rapid diagnostic tests for malaria into registered drug shops in Uganda: lessons learned and policy implications.

    PubMed

    Mbonye, Anthony K; Clarke, Sîan E; Lal, Sham; Chandler, Clare I; Hutchinson, Eleanor; Hansen, Kristian S; Magnussen, Pascal

    2015-11-14

    Malaria is a major public health problem in Uganda and the current policy recommends introduction of rapid diagnostic tests for malaria (RDTs) to facilitate effective case management. However, provision of RDTs in drug shops potentially raises a new set of issues, such as adherence to RDTs results, management of severe illnesses, referral of patients, and relationship with caretakers. The main objective of the study was to examine the impact of introducing RDTs in registered drug shops in Uganda and document lessons and policy implications for future scale-up of malaria control in the private health sector. A cluster-randomized trial introducing RDTs into registered drug shops was implemented in central Uganda from October 2010 to July 2012. An evaluation was undertaken to assess the impact and the processes involved with the introduction of RDTs into drug shops, the lessons learned and policy implications. Introducing RDTs into drug shops was feasible. To scale-up this intervention however, drug shop practices need to be regulated since the registration process was not clear, supervision was inadequate and record keeping was poor. Although initially it was anticipated that introducing a new practice of record keeping would be cumbersome, but at evaluation this was not found to be a constraint. This presents an important lesson for introducing health management information system into drug shops. Involving stakeholders, especially the district health team, in the design was important for ownership and sustainability. The involvement of village health teams in community sensitization to the new malaria treatment and diagnosis policy was a success and this strategy is recommended for future interventions. Introducing RDTs into drug shops was feasible and it increased appropriate treatment of malaria with artemisinin-based combination therapy. It is anticipated that the lessons presented will help better implementation of similar interventions in the private sector.

  5. Designing to Sample the Unknown: Lessons from OSIRIS-REx Project Systems Engineering

    NASA Technical Reports Server (NTRS)

    Everett, David; Mink, Ronald; Linn, Timothy; Wood, Joshua

    2017-01-01

    On September 8, 2016, the third NASA New Frontiers mission launched on an Atlas V 411. The Origins, Spectral Interpretation, Resource Identification, Security-Regolith Explorer (OSIRIS-REx) will rendezvous with asteroid Bennu in 2018, collect a sample in 2020, and return that sample to Earth in September 2023. The development team has overcome a number of challenges in order to design and build a system that will make contact with an unexplored, airless, low-gravity body. This paper will provide an overview of the mission, then focus in on the system-level challenges and some of the key system-level processes. Some of the lessons here are unique to the type of mission, like discussion of operating at a largely-unknown, low-gravity object. Other lessons, particularly from the build phase, have broad implications. The OSIRIS-REx risk management process was particularly effective in achieving an on-time and under-budget development effort. The systematic requirements management and verification and the system validation also helped identify numerous potential problems. The final assessment of the OSIRIS-REx performance will need to wait until the sample is returned in 2023, but this post-launch assessment will capture some of the key systems-engineering lessons from the development team.

  6. Implementing the Community Health Worker Model within Diabetes Management: Challenges and Lessons Learned from Programs across the U.S.

    PubMed Central

    Cherrington, Andrea; Ayala, Guadalupe X.; Amick, Halle; Allison, Jeroan; Corbie-Smith, Giselle; Scarinci, Isabel

    2018-01-01

    Introduction/objectives The Community Health Worker (CHW) model has gained popularity as a method for reaching vulnerable populations with diabetes mellitus (DM), yet little is known about its actual role in program delivery. The purpose of this qualitative study was to examine methods of implementation as well as related challenges and lessons learned. Methods Semi-structured interviews were conducted with program managers. Four databases (PubMed, CINAHL, ISI Web of Knowledge, PsycInfo), the CDC’s 1998 directory of CHW programs and Google Search Engine and were used to identify CHW programs. Criteria for inclusion were: DM program; used CHW strategy; occurred in United States. Two independent reviewers performed content analyses to identify major themes and findings. Results Sixteen programs were assessed, all but three focused on minority populations. Most CHWs were recruited informally; six programs required CHWs to have diabetes. CHW roles and responsibilities varied across programs; educator was the most commonly identified role. Training also varied in terms of both content and intensity. All programs gave CHWs remuneration for their work. Common challenges included difficulties with CHW retention, intervention fidelity and issues related to sustainability. Cultural and gender issues also emerged. Examples of lessons learned included the need for community buy-in and the need to anticipate non-diabetes related issues. Conclusions Lessons learned from these programs may be useful to others as they apply the CHW model to diabetes management within their own communities. Further research is needed to elucidate the specific features of this model necessary to positively impact health outcomes. PMID:18832287

  7. The surgical learning and instructional portfolio: what residents at a single institution are learning.

    PubMed

    Webb, Travis P; Merkley, Taylor R

    2011-03-01

    The Accreditation Council for Graduate Medical Education (ACGME) Learning Portfolio is recommended as a tool to develop and document reflective, practice-based learning and improvement. There is no consensus regarding the appropriate content of a learning portfolio in medical education. Studying lessons selected for inclusion in their learning portfolios by surgical trainees could help identify useful subject matter for this purpose. Each month, all residents in our surgery residency program submit entries into their individual Surgical Learning and Instructional Portfolio (SLIP). The SLIP entries from July 2008 to 2009 (n = 420) were deidentified and randomized using a random number generator. We conducted a thematic content analysis of 50 random portfolio entries to identify lessons learned. Two independent raters analyzed the "3 lessons learned" portion of the portfolio entries and identified themes and subthemes using the constant comparative method used in grounded theory. The collaborative coding process resulted in theme saturation after the identification of 7 themes and their subthemes. Themes in decreasing order of frequency included complications, disease epidemiology, disease presentation, surgical management of disease, medical management of disease, operative techniques, and pathophysiology. Junior residents chose to focus on a broad array of foundational topics including disease presentation, epidemiology, and overall management of diseases, whereas postgraduate year-4 (PGY-4) and PGY-5 residents most frequently chose to focus on complications as learning points. Lessons learned reflect perceived needs of the trainees based on training year. When given a template to follow, junior and senior residents choose to reflect on different subject matter to meet their learning goals.

  8. The Surgical Learning and Instructional Portfolio: What Residents at a Single Institution Are Learning

    PubMed Central

    Webb, Travis P; Merkley, Taylor R

    2011-01-01

    Background The Accreditation Council for Graduate Medical Education (ACGME) Learning Portfolio is recommended as a tool to develop and document reflective, practice-based learning and improvement. There is no consensus regarding the appropriate content of a learning portfolio in medical education. Studying lessons selected for inclusion in their learning portfolios by surgical trainees could help identify useful subject matter for this purpose. Methods Each month, all residents in our surgery residency program submit entries into their individual Surgical Learning and Instructional Portfolio (SLIP). The SLIP entries from July 2008 to 2009 (n = 420) were deidentified and randomized using a random number generator. We conducted a thematic content analysis of 50 random portfolio entries to identify lessons learned. Two independent raters analyzed the “3 lessons learned” portion of the portfolio entries and identified themes and subthemes using the constant comparative method used in grounded theory. Results The collaborative coding process resulted in theme saturation after the identification of 7 themes and their subthemes. Themes in decreasing order of frequency included complications, disease epidemiology, disease presentation, surgical management of disease, medical management of disease, operative techniques, and pathophysiology. Junior residents chose to focus on a broad array of foundational topics including disease presentation, epidemiology, and overall management of diseases, whereas postgraduate year-4 (PGY-4) and PGY-5 residents most frequently chose to focus on complications as learning points. Conclusions Lessons learned reflect perceived needs of the trainees based on training year. When given a template to follow, junior and senior residents choose to reflect on different subject matter to meet their learning goals. PMID:22379531

  9. Kitchen Physics: Lessons in Fluid Pressure and Error Analysis

    NASA Astrophysics Data System (ADS)

    Vieyra, Rebecca Elizabeth; Vieyra, Chrystian; Macchia, Stefano

    2017-02-01

    Although the advent and popularization of the "flipped classroom" tends to center around at-home video lectures, teachers are increasingly turning to at-home labs for enhanced student engagement. This paper describes two simple at-home experiments that can be accomplished in the kitchen. The first experiment analyzes the density of four liquids using a waterproof case and a smartphone barometer in a container, sink, or tub. The second experiment determines the relationship between pressure and temperature of an ideal gas in a constant volume container placed momentarily in a refrigerator freezer. These experiences provide a ripe opportunity both for learning fundamental physics concepts as well as to investigate a variety of error analysis techniques that are frequently overlooked in introductory physics courses.

  10. Scaling up HIV viral load - lessons from the large-scale implementation of HIV early infant diagnosis and CD4 testing.

    PubMed

    Peter, Trevor; Zeh, Clement; Katz, Zachary; Elbireer, Ali; Alemayehu, Bereket; Vojnov, Lara; Costa, Alex; Doi, Naoko; Jani, Ilesh

    2017-11-01

    The scale-up of effective HIV viral load (VL) testing is an urgent public health priority. Implementation of testing is supported by the availability of accurate, nucleic acid based laboratory and point-of-care (POC) VL technologies and strong WHO guidance recommending routine testing to identify treatment failure. However, test implementation faces challenges related to the developing health systems in many low-resource countries. The purpose of this commentary is to review the challenges and solutions from the large-scale implementation of other diagnostic tests, namely nucleic-acid based early infant HIV diagnosis (EID) and CD4 testing, and identify key lessons to inform the scale-up of VL. Experience with EID and CD4 testing provides many key lessons to inform VL implementation and may enable more effective and rapid scale-up. The primary lessons from earlier implementation efforts are to strengthen linkage to clinical care after testing, and to improve the efficiency of testing. Opportunities to improve linkage include data systems to support the follow-up of patients through the cascade of care and test delivery, rapid sample referral networks, and POC tests. Opportunities to increase testing efficiency include improvements to procurement and supply chain practices, well connected tiered laboratory networks with rational deployment of test capacity across different levels of health services, routine resource mapping and mobilization to ensure adequate resources for testing programs, and improved operational and quality management of testing services. If applied to VL testing programs, these approaches could help improve the impact of VL on ART failure management and patient outcomes, reduce overall costs and help ensure the sustainable access to reduced pricing for test commodities, as well as improve supportive health systems such as efficient, and more rigorous quality assurance. These lessons draw from traditional laboratory practices as well as fields such as logistics, operations management and business. The lessons and innovations from large-scale EID and CD4 programs described here can be adapted to inform more effective scale-up approaches for VL. They demonstrate that an integrated approach to health system strengthening focusing on key levers for test access such as data systems, supply efficiencies and network management. They also highlight the challenges with implementation and the need for more innovative approaches and effective partnerships to achieve equitable and cost-effective test access. © 2017 The Authors. Journal of the International AIDS Society published by John Wiley & sons Ltd on behalf of the International AIDS Society.

  11. Lessons Learned Coaching Teachers in Behavior Management: The PBISplus Coaching Model

    PubMed Central

    Hershfeldt, Patricia A.; Pell, Karen; Sechrest, Richard; Pas, Elise T.; Bradshaw, Catherine P.

    2013-01-01

    There is growing interest in coaching as a means of promoting professional development and the use of evidence-based practices in schools. This paper describes the PBISplus coaching model used to provide technical assistance for classroom- and school-wide behavior management to elementary schools over the course of three years. This tier-two coaching model was implemented within the context of school-wide Positive Behavioral Interventions and Supports (PBIS) and tested in a 42-school randomized controlled trial. We summarize some of the lessons learned by coaches regarding their efforts to gain access to the administrators, teachers, and student support staff in order to effect change and improve student outcomes. We conclude with a discussion of ways to successfully collaborate with teachers to promote effective classroom- and school-wide behavior management. PMID:23599661

  12. Lessons Learned on Effective Co-production of Drought Science and Decision Support Tools with the Wind River Reservation Tribal Water Managers

    NASA Astrophysics Data System (ADS)

    McNeeley, S.; Ojima, D. S.; Beeton, T.

    2015-12-01

    The Wind River Reservation in west-central Wyoming is home of the Eastern Shoshone and Northern Arapaho Tribes. The reservation has experienced severe drought impacts on Tribal livelihoods and cultural activities in recent years. Scientists from the North Central Climate Science Center, the National Drought Mitigation Center, the High Plains Regional Climate Center, and multiple others are working in close partnership with the tribal water managers on a reservation-wide drought preparedness project that includes a technical assessment of drought risk, capacity building to train managers on drought and climate science and indicators, and drought planning. This talk will present project activities to date along with the valuable and transferrable lessons learned on effective co-production of actionable science for decision making in a tribal context.

  13. Radiation-Hardened Solid-State Drive

    NASA Technical Reports Server (NTRS)

    Sheldon, Douglas J.

    2010-01-01

    A method is provided for a radiationhardened (rad-hard) solid-state drive for space mission memory applications by combining rad-hard and commercial off-the-shelf (COTS) non-volatile memories (NVMs) into a hybrid architecture. The architecture is controlled by a rad-hard ASIC (application specific integrated circuit) or a FPGA (field programmable gate array). Specific error handling and data management protocols are developed for use in a rad-hard environment. The rad-hard memories are smaller in overall memory density, but are used to control and manage radiation-induced errors in the main, and much larger density, non-rad-hard COTS memory devices. Small amounts of rad-hard memory are used as error buffers and temporary caches for radiation-induced errors in the large COTS memories. The rad-hard ASIC/FPGA implements a variety of error-handling protocols to manage these radiation-induced errors. The large COTS memory is triplicated for protection, and CRC-based counters are calculated for sub-areas in each COTS NVM array. These counters are stored in the rad-hard non-volatile memory. Through monitoring, rewriting, regeneration, triplication, and long-term storage, radiation-induced errors in the large NV memory are managed. The rad-hard ASIC/FPGA also interfaces with the external computer buses.

  14. Integrated corridor management initiative : demonstration phase evaluation, San Diego decision support system analysis test plan.

    DOT National Transportation Integrated Search

    2000-01-01

    This report demonstrates the benefits and potential pitfalls of deploying and operating an integrated freeway and arterial management system. In particular, it discusses the lessons learned about the Medical Center Corridor (MCC) Project deployed in ...

  15. Enterprise transformation :lessons learned, pathways to success.

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Slavin, Adam M.; Woodard, Joan Brune

    2006-05-01

    In this report, we characterize the key themes of transformation and tie them together in a ''how to'' guide. The perspectives were synthesized from strategic management literature, case studies, and from interviews with key management personnel from private industry on their transformation experiences.

  16. Emergency Management Benchmarking Study: Lessons for Increasing Supply Chain Resilience

    DTIC Science & Technology

    2010-03-01

    studied if public-private partnerships could improve community resilience . In essence they concluded that in order to achieve community resilience , public...improve community resilience in times of disaster. International Journal of Physical Distribution & Logistics Management, Vol. 39, No. 5, pp. 343

  17. Nurses' attitude and intention of medication administration error reporting.

    PubMed

    Hung, Chang-Chiao; Chu, Tsui-Ping; Lee, Bih-O; Hsiao, Chia-Chi

    2016-02-01

    The Aims of this study were to explore the effects of nurses' attitudes and intentions regarding medication administration error reporting on actual reporting behaviours. Underreporting of medication errors is still a common occurrence. Whether attitude and intention towards medication administration error reporting connect to actual reporting behaviours remain unclear. This study used a cross-sectional design with self-administered questionnaires, and the theory of planned behaviour was used as the framework for this study. A total of 596 staff nurses who worked in general wards and intensive care units in a hospital were invited to participate in this study. The researchers used the instruments measuring nurses' attitude, nurse managers' and co-workers' attitude, report control, and nurses' intention to predict nurses' actual reporting behaviours. Data were collected from September-November 2013. Path analyses were used to examine the hypothesized model. Of the 596 nurses invited to participate, 548 (92%) completed and returned a valid questionnaire. The findings indicated that nurse managers' and co-workers' attitudes are predictors for nurses' attitudes towards medication administration error reporting. Nurses' attitudes also influenced their intention to report medication administration errors; however, no connection was found between intention and actual reporting behaviour. The findings reflected links among colleague perspectives, nurses' attitudes, and intention to report medication administration errors. The researchers suggest that hospitals should increase nurses' awareness and recognition of error occurrence. Regardless of nurse managers' and co-workers' attitudes towards medication administration error reporting, nurses are likely to report medication administration errors if they detect them. Management of medication administration errors should focus on increasing nurses' awareness and recognition of error occurrence. © 2015 John Wiley & Sons Ltd.

  18. Supply chain management/ Some lessons learned the hard way.

    PubMed

    Nuttall, Stephen

    2013-01-01

    This paper will look at some of the experiences, lessons and frustrations experienced in managing supply chains for business continuity. No-one has time to make all the mistakes, nor to learn all the lessons on their own, so it is useful to share experiences. Over the last 25 years, the author has been involved in supply chain management as a contract manager; a programme and project manager; and as a business continuity manager. Although times change, there are some fundamental principles that are absolutely critical in making sure that supply chains do what they are needed to do/ to keep business going. Supply chains are here to stay. Indeed, with today's drive towards outsourcing, best-shoring and contracting out, they are becoming more important every year and this will only continue over time. Moreover, in the highly competitive markets in which all organisations operate, suppliers may well be carrying out operations that not all that long ago would have been considered to be part of core business. Getting the right relationship with the supply chain is more critical than ever before.1 What does this mean to business continuity professionals? They need to think not just about their own BC plans, but about the plans of their suppliers, and even those of their suppliers' suppliers. This may seem obvious, but unlike internal BC plans written by and for an organisation, it must be considered just what a supplier's plans are designed to achieve. What business outcomes will their plans deliver? If they recover their own business, how does that affect the business they serve? Are others' assumptions of how they will react in line with theirs?

  19. Issues in NASA Program and Project Management. Special Report: 1997 Conference. Project Management Now and in the New Millennium

    NASA Technical Reports Server (NTRS)

    Hoffman, Edward J. (Editor); Lawbaugh, William M. (Editor)

    1997-01-01

    Topics Considered Include: NASA's Shared Experiences Program; Core Issues for the Future of the Agency; National Space Policy Strategic Management; ISO 9000 and NASA; New Acquisition Initiatives; Full Cost Initiative; PM Career Development; PM Project Database; NASA Fast Track Studies; Fast Track Projects; Earned Value Concept; Value-Added Metrics; Saturn Corporation Lessons Learned; Project Manager Credibility.

  20. Operational approaches to managing forests of the future in Mediterranean regions within a context of changing climates

    Treesearch

    Scott L. Stephens; Constance I. Millar; Brandon M. Collins

    2010-01-01

    Many US forest managers have used historical ecology information to assist in the development of desired conditions. While there are many important lessons to learn from the past, we believe that we cannot rely on past forest conditions to provide us with blueprints for future management. To respond to this uncertainty, managers will be challenged to integrate...

  1. Wheel speed management control system for spacecraft

    NASA Technical Reports Server (NTRS)

    Goodzeit, Neil E. (Inventor); Linder, David M. (Inventor)

    1991-01-01

    A spacecraft attitude control system uses at least four reaction wheels. In order to minimize reaction wheel speed and therefore power, a wheel speed management system is provided. The management system monitors the wheel speeds and generates a wheel speed error vector. The error vector is integrated, and the error vector and its integral are combined to form a correction vector. The correction vector is summed with the attitude control torque command signals for driving the reaction wheels.

  2. Spent Nuclear Fuel Trasportation: An Examination of Potential Lessons Learned From Prior Shipping Campaigns

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    M. Keister; K, McBride

    The Nuclear Waste Policy Act of 1982 (NWPA), as amended, assigned the Department of Energy (DOE) responsibility for developing and managing a Federal system for the disposal of spent nuclear fuel (SNF) and high-level radioactive waste (HLW). The Office of Civilian Radioactive Waste Management (OCRWM) is responsible for accepting, transporting, and disposing of SNF and HLW at the Yucca Mountain repository (if licensed) in a manner that protects public health, safety, and the environment; enhances national and energy security; and merits public confidence. OCRWM faces a near-term challenge--to develop and demonstrate a transportation system that will sustain safe and efficientmore » shipments of SNF and HLW to a repository. To better inform and improve its current planning, OCRWM has extensively reviewed plans and other documents related to past high-visibility shipping campaigns of SNF and other radioactive materials within the United States. This report summarizes the results of this review and, where appropriate, lessons learned. The objective of this lessons learned study was to identify successful, best-in-class trends and commonalities from past shipping campaigns, which OCRWM could consider when planning for the development and operation of a repository transportation system. Note: this paper is for analytical and discussion purposes only, and is not an endorsement of, or commitment by, OCRWM to follow any of the comments or trends. If OCRWM elects to make such commitments at a future time, they will be appropriately documented in formal programmatic policy statements, plans and procedures. Reviewers examined an extensive study completed in 2003 by DOE's National Transportation Program (NTP), Office of Environmental Management (EM), as well as plans and documents related to SNF shipments since issuance of the NTP report. OCRWM examined specific planning, business, institutional and operating practices that have been identified by DOE, its transportation contractors, and stakeholders as important issues that arise repeatedly. In addition, the review identifies lessons learned or activities/actions which were found not to be productive to the planning and conduct of SNF shipments (i.e., negative impacts). This paper is a 'looking back' summary of lessons learned across multiple transportation campaigns. Not all lessons learned are captured here, and participants in some of the campaigns have divergent opinions and perspectives about which lessons are most critical. This analysis is part of a larger OCRWM benchmarking effort to identify best practices to consider in future transportation of radioactive materials ('looking forward'). Initial findings from this comprehensive benchmarking analysis are expected to be available in late fall 2006.« less

  3. Teachers' Perceptions of the Integrated Quality Management System: Lessons from Mpumalanga, South Africa

    ERIC Educational Resources Information Center

    Queen-Mary, Thobela Nozidumo; Mtapuri, Oliver

    2014-01-01

    This article examines the attitudes and perceptions of teachers regarding the implementation of the Integrated Quality Management System (IQMS). In doing so, it aims to contribute to the global discourse of change management in education. The system is intended to develop educators by enhancing their capabilities to inculcate a culture of teaching…

  4. Alberta's systems approach to chronic disease management and prevention utilizing the expanded chronic care model.

    PubMed

    Delon, Sandra; Mackinnon, Blair

    2009-01-01

    Alberta's integrated approach to chronic disease management programming embraces client-centred care, supports self-management and facilitates care across the continuum. This paper presents strategies implemented through collaboration with primary care to improve care of individuals with chronic conditions, evaluation evidence supporting success and lessons learned from the Alberta perspective.

  5. Mission management - Lessons learned from early Spacelab missions

    NASA Technical Reports Server (NTRS)

    Craft, H. G., Jr.

    1980-01-01

    The concept and the responsibilities of a mission manager approach are reviewed, and some of the associated problems in implementing Spacelab mission are discussed. Consideration is given to program control, science management, integrated payload mission planning, and integration requirements. Payload specialist training, payload and launch site integration, payload flight/mission operations, and postmission activities are outlined.

  6. A Lesson for American Managers: Learning from Japanese Experiences in the U.S.

    ERIC Educational Resources Information Center

    Nosow, Sigmund

    1984-01-01

    Research finds that, in Japanese-owned plants in America, efforts are made to bring the system around slowly to a Japanese management style through acculturation, communication, and training. Problems engendered by these efforts emerge particularly at the middle management levels. Barriers to corporate unity are far fewer at the plant level. (CT)

  7. Mississippi Curriculum Framework for Agriculture Business and Management (Program CIP: 01.0101--Agriculture Business & Mgmt., Gen.). Secondary Programs.

    ERIC Educational Resources Information Center

    Mississippi Research and Curriculum Unit for Vocational and Technical Education, State College.

    This document, which reflects Mississippi's statutory requirement that instructional programs be based on core curricula and performance-based assessment, contains outlines of the instructional units required in local instructional management plans and daily lesson plans for agriculture business and management (ABM) I and II. Presented first are a…

  8. Strategies for Meeting High Standards: Quality Management and the Baldrige Criteria in Education. Lessons from the States.

    ERIC Educational Resources Information Center

    Barth, John; Burk, Zona Sharp; Serfass, Richard; Harms, Barbara Ann; Houlihan, G. Thomas; Anderson, Gerald; Farley, Raymond P.; Rigsby, Ken; O'Rourke, John

    This document, one of a series of reports, focuses on the adoption of principles of quality management, originally developed by W. Edwards Deming, and the Baldrige Criteria for use in education. These processes and tools for systemic organizational management, when comprehensively applied, produce performance excellence and continuous improvement.…

  9. More than a Marriage of Convenience: The Convergence of Management and Indigenous Educational Practice

    ERIC Educational Resources Information Center

    Nursey-Bray, Melissa; Haugstetter, Hilary

    2011-01-01

    In today's globalized world, there is an increasing imperative to operate in multiple and culturally diverse contexts. An intercultural approach to management education prepares students to work anywhere in the world. What lessons can be learned from other cultures that can enhance how managers operate in international forums? The authors seek to…

  10. Oak woodland conservation management planning in southern CA - lessons learned

    Treesearch

    Rosi Dagit

    2015-01-01

    The California Oak Woodlands Conservation Act (AB 242 2001) established requirements for the preservation and protection of oak woodlands and trees, and allocated funding managed by the Wildlife Conservation Board. In order to qualify to use these funds, counties and cities need to adopt an oak conservation management plan. Between 2008 and 2011, a team of concerned...

  11. Collaborative Classroom Management in a Co-Taught Primary School Classroom

    ERIC Educational Resources Information Center

    Rytivaara, Anna

    2012-01-01

    The purpose of this study was to examine how teachers manage their classroom in co-taught lessons. The data were collected by observing and interviewing a pair of primary school teachers. The most important influence of collaboration on classroom management seemed to be the emotional support of another adult, and the opportunity to use different…

  12. Eisenhower and Manstein: Operational Leadership Lessons of the Past for Today’s Commanders

    DTIC Science & Technology

    2007-05-10

    development of warriors and leaders as opposed to managers . Leadership requires continuous training and challenge throughout ones career. In peacetime it...FINAL 3. DATES COVERED (From - To) 4. TITLE AND SUBTITLE Eisenhower and Manstein: Operational Leadership Lessons of the 5a. CONTRACT...servicemen and women. Without effective leadership these men and women are ill-equipped to succeed in combat and are unjustly put in harms way. The

  13. Sustaining Equipment and the Rapid Acquisition Process: The Forgotten Phase

    DTIC Science & Technology

    2012-02-24

    Operation of the Defense Acquisition System,” December 8, 2008. 7 Rasch , Robert. A, Jr. Lessons Learned from Rapid Acquisition: Better, Faster, Cheaper...Life Cycle Management Responsibilities,” Defense AR Journal, 17.2 (April 2010): 183. 37 Robert A. Rasch , Lessons Learned from Rapid Acquisition: Better...Accountability Office (GAO) Report, Subject: Rapid Acquisition of Mine Resistant Protected Vehicles, July 15, 2008, 4. 39 Ibid. 40 Ibid. 41 Robert A. Rasch

  14. Bayes, Bugs, and Bioterrorists: Lessons Learned from the Anthrax Attacks

    DTIC Science & Technology

    2005-04-01

    characteristics of Bacillus anthracis, the causative organism. Anthrax was known primarily as a disease of cattle, sheep, and other types of livestock, but it...REPORT TYPE N/A 3. DATES COVERED - 4. TITLE AND SUBTITLE Bayes, Bugs, and Bioterrorists: Lessons Learned from the Anthrax Attacks 5a. CONTRACT...develop a strategy for managing the risks of bioterrorism. Using this type of approach, the government can better characterize the costs, risks and

  15. Risk management and lessons learned solutions for satellite product assurance

    NASA Astrophysics Data System (ADS)

    Larrère, Jean-Luc

    2004-08-01

    The historic trend of the space industry towards lower cost programmes and more generally a better economic efficiency raises a difficult question to the quality assurance community: how to achieve the same—or better—mission success rate while drastically reducing the cost of programmes, hence the cost and level of quality assurance activities. EADS Astrium Earth Observation and Science (France) Business Unit have experimented Risk Management and Lessons Learned on their satellite programmes to achieve this goal. Risk analysis and management are deployed from the programme proposal phase through the development and operations phases. Results of the analysis and the corresponding risk mitigation actions are used to tailor the product assurance programme and activities. Lessons learned have been deployed as a systematic process to collect positive and negative experience from past and on-going programmes and feed them into new programmes. Monitoring and justification of their implementation in programmes is done under supervision from the BU quality assurance function. Control of the system is ensured by the company internal review system. Deployment of these methods has shown that the quality assurance function becomes more integrated in the programme team and development process and that its tasks gain focus and efficiency while minimising the risks associated with new space programmes.

  16. 2010 CEOS Field Reflectance Intercomparisons Lessons Learned

    NASA Technical Reports Server (NTRS)

    Thome, Kurtis; Fox, Nigel

    2011-01-01

    This paper summarizes lessons learned from the 2009 and 2010 joint field campaigns to Tuz Golu, Turkey. Emphasis is placed on the 2010 campaign related to understanding the equipment and measurement protocols, processing schemes, and traceability to SI quantities. Participants in both 2009 and 2010 used an array of measurement approaches to determine surface reflectance. One lesson learned is that even with all of the differences in collection between groups, the differences in reflectance are currently dominated by instrumental artifacts including knowledge of the white reference. Processing methodology plays a limited role once the bi-directional reflectance of the white reference is used rather than a hemispheric-directional value. The lack of a basic set of measurement protocols, or best practices, limits a group s ability to ensure SI traceability and the development of proper error budgets. Finally, rigorous attention to sampling methodology and its impact on instrument behavior is needed. The results of the 2009 and 2010 joint campaigns clearly demonstrate both the need and utility of such campaigns and such comparisons must continue in the future to ensure a coherent set of data that can span multiple sensor types and multiple decades.

  17. Rethinking Combat Identification. Joint Center for Lessons Learned Quarterly Bulletin. Volume 4, Issue 3, June 2002

    DTIC Science & Technology

    2002-06-01

    Countermeasures Unit Chief Special Events Management Unit Chief Domestic Terrorism/ Counterterrorism Section Chief International Terrorism Section...Asstistant Director Counter- Terrorism Division Figure 3 Division/Section/Unit Hierarchies The LNO also supports the Special Events Management Unit (SEMU

  18. Rehabilitation of cheatgrass-infested rangelands: management

    USDA-ARS?s Scientific Manuscript database

    This is the final part of a three part series specifically addressing lessons learned concerning the management of rehabilitated cheatgrass-infested rangelands. Steve Novak and Richard Mack reported in 2003 that they found no evidence of outcrossing in 2,000 cheatgrass seedlings from 60 North Americ...

  19. Developing a Virtual Engineering Management Community

    ERIC Educational Resources Information Center

    Hewitt, Bill; Kidd, Moray; Smith, Robin; Wearne, Stephen

    2016-01-01

    The paper reviews the lessons of planning and running an "Engineering Management" practitioner development programme in a partnership between BP and the University of Manchester. This distance-learning programme is for professional engineers in mid-career experienced in the engineering and support activities for delivering safe,…

  20. [What Surgeons Should Know about Risk Management].

    PubMed

    Strametz, R; Tannheimer, M; Rall, M

    2017-02-01

    Background: The fact that medical treatment is associated with errors has long been recognized. Based on the principle of "first do no harm", numerous efforts have since been made to prevent such errors or limit their impact. However, recent statistics show that these measures do not sufficiently prevent grave mistakes with serious consequences. Preventable mistakes such as wrong patient or wrong site surgery still frequently occur in error statistics. Methods: Based on insight from research on human error, in due consideration of recent legislative regulations in Germany, the authors give an overview of the clinical risk management tools needed to identify risks in surgery, analyse their causes, and determine adequate measures to manage those risks depending on their relevance. The use and limitations of critical incident reporting systems (CIRS), safety checklists and crisis resource management (CRM) are highlighted. Also the rationale for IT systems to support the risk management process is addressed. Results/Conclusion: No single tool of risk management can be effective as a standalone instrument, but unfolds its effect only when embedded in a superordinate risk management system, which integrates tailor-made elements to increase patient safety into the workflows of each organisation. Competence in choosing adequate tools, effective IT systems to support the risk management process as well as leadership and commitment to constructive handling of human error are crucial components to establish a safety culture in surgery. Georg Thieme Verlag KG Stuttgart · New York.

  1. [Risk Management: concepts and chances for public health].

    PubMed

    Palm, Stefan; Cardeneo, Margareta; Halber, Marco; Schrappe, Matthias

    2002-01-15

    Errors are a common problem in medicine and occur as a result of a complex process involving many contributing factors. Medical errors significantly reduce the safety margin for the patient and contribute additional costs in health care delivery. In most cases adverse events cannot be attributed to a single underlying cause. Therefore an effective risk management strategy must follow a system approach, which is based on counting and analysis of near misses. The development of defenses against the undesired effects of errors should be the main focus rather than asking the question "Who blundered?". Analysis of near misses (which in this context can be compared to indicators) offers several methodological advantages as compared to the analysis of errors and adverse events. Risk management is an integral element of quality management.

  2. International Space Station Passive Thermal Control System Analysis, Top Ten Lessons-Learned

    NASA Technical Reports Server (NTRS)

    Iovine, John

    2011-01-01

    The International Space Station (ISS) has been on-orbit for over 10 years, and there have been numerous technical challenges along the way from design to assembly to on-orbit anomalies and repairs. The Passive Thermal Control System (PTCS) management team has been a key player in successfully dealing with these challenges. The PTCS team performs thermal analysis in support of design and verification, launch and assembly constraints, integration, sustaining engineering, failure response, and model validation. This analysis is a significant body of work and provides a unique opportunity to compile a wealth of real world engineering and analysis knowledge and the corresponding lessons-learned. The analysis lessons encompass the full life cycle of flight hardware from design to on-orbit performance and sustaining engineering. These lessons can provide significant insight for new projects and programs. Key areas to be presented include thermal model fidelity, verification methods, analysis uncertainty, and operations support.

  3. What lessons can history teach us about the Charcot foot?

    PubMed

    Sanders, Lee J

    2008-01-01

    Regrettably, physicians today receive very little instruction in the history of medicine. Most health care providers have a very limited, contemporary knowledge of the condition that we know of as the Charcot foot. Yet, historical concepts of the pathogenesis and natural history of this condition provide us with important lessons that enhance our understanding, recognition, and management of this rare but debilitating neurogenic arthropathy. It is my belief that knowledge of the history of medicine provides us with a better understanding of present-day issues and clearer vision as we look to the future. This article describes some of the important lessons learned from the history of the Charcot foot.

  4. Sailor Relationship Management: The Use of Customer Relationship Management in Sailor Morale and Retention

    DTIC Science & Technology

    2002-08-16

    advances in information technology. Customer Relationship Management ( CRM ) is a concept that has personalized the marketing process over the Internet. An...even newer concept, Employee Relationship Management (ERM), seeks to turn the lessons learned from CRM inwards to a company’s own employees, not to...within the Navy, resulting in Sailor Relationship Management (SRM.) The work included focus group interviews that led to the development of a survey

  5. The ethics and practical importance of defining, distinguishing and disclosing nursing errors: a discussion paper.

    PubMed

    Johnstone, Megan-Jane; Kanitsaki, Olga

    2006-03-01

    Nurses globally are required and expected to report nursing errors. As is clearly demonstrated in the international literature, fulfilling this requirement is not, however, without risks. In this discussion paper, the notion of 'nursing error', the practical and moral importance of defining, distinguishing and disclosing nursing errors and how a distinct definition of 'nursing error' fits with the new 'system approach' to human-error management in health care are critiqued. Drawing on international literature and two key case exemplars from the USA and Australia, arguments are advanced to support the view that although it is 'right' for nurses to report nursing errors, it will be very difficult for them to do so unless a non-punitive approach to nursing-error management is adopted.

  6. Medical professional liability insurance and its relation to medical error and healthcare risk management for the practicing physician.

    PubMed

    Abbott, Richard L; Weber, Paul; Kelley, Betsy

    2005-12-01

    To review the history and current issues surrounding medical professional liability insurance and its relationship to medical error and healthcare risk management. Focused literature review and authors' experience. Medical professional liability insurance issues are reviewed in association with the occurrence of medical error and the role of healthcare risk management. The rising frequency and severity of claims and lawsuits incurred by physicians, as well as escalating defense costs, have dramatically increased over the past several years and have resulted in accelerated efforts to reduce medical errors and control practice risk for physicians. Medical error reduction and improved patient outcomes are closely linked to the goals of the medical risk manager by reducing exposure to adverse medical events. Management of professional liability risk by the physician-led malpractice insurance company not only protects the economic viability of physicians, but also addresses patient safety concerns. Physician-owned malpractice liability insurance companies will continue to be the dominant providers of insurance for practicing physicians and will serve as the primary source for loss prevention and risk management services. To succeed in the marketplace, the emergence and importance of the risk manager and incorporation of risk management principles throughout the professional liability company has become crucial to the financial stability and success of the insurance company. The risk manager provides the necessary advice and support requested by physicians to minimize medical liability risk in their daily practice.

  7. How Helpful Are Error Management and Counterfactual Thinking Instructions to Inexperienced Spreadsheet Users' Training Task Performance?

    ERIC Educational Resources Information Center

    Caputi, Peter; Chan, Amy; Jayasuriya, Rohan

    2011-01-01

    This paper examined the impact of training strategies on the types of errors that novice users make when learning a commonly used spreadsheet application. Fifty participants were assigned to a counterfactual thinking training (CFT) strategy, an error management training strategy, or a combination of both strategies, and completed an easy task…

  8. Error Management Practices Interacting with National and Organizational Culture: The Case of Two State University Departments in Turkey

    ERIC Educational Resources Information Center

    Göktürk, Söheyda; Bozoglu, Oguzhan; Günçavdi, Gizem

    2017-01-01

    Purpose: Elements of national and organizational cultures can contribute much to the success of error management in organizations. Accordingly, this study aims to consider how errors were approached in two state university departments in Turkey in relation to their specific organizational and national cultures. Design/methodology/approach: The…

  9. Managing variation in demand: lessons from the UK National Health Service.

    PubMed

    Walley, Paul; Silvester, Kate; Steyn, Richard

    2006-01-01

    Managers within the U.S. healthcare system are becoming more aware of the impact of variation in demand on healthcare processes. The UK National Health Service provides a prime example of a system that has experienced the consequences when the issue is not dealt with satisfactorily, having suffered from excessive queues for a prolonged period. These delays are mostly caused by a lack of attention to variation and inappropriate responses to the queues, rather than a capacity shortage. A number of collaborative programs recently have come to grips with many of the causes of the queues in both elective care and emergency care. Although there are still areas that need large-scale improvement, good progress has been made, especially within emergency care. The authors of this article have acted as technical advisors to a number of these improvement programs and have been able to document many of the practices that have helped to reduce or eliminate unnecessary queues and delays across the 200 sites in England that have 24-hour emergency care facilities. Local program managers at these sites continuously reported progress for a period of 18 months. A number of important lessons for both the design and control of healthcare processes have emerged from the collaborative work. These lessons focus on understanding and measurement of demand, capacity planning, reduction of introduced variation, segmentation and streaming of work, process design, capacity yield management, and measurement of variation.

  10. Acquisition of Malay word recognition skills: lessons from low-progress early readers.

    PubMed

    Lee, Lay Wah; Wheldall, Kevin

    2011-02-01

    Malay is a consistent alphabetic orthography with complex syllable structures. The focus of this research was to investigate word recognition performance in order to inform reading interventions for low-progress early readers. Forty-six Grade 1 students were sampled and 11 were identified as low-progress readers. The results indicated that both syllable awareness and phoneme blending were significant predictors of word recognition, suggesting that both syllable and phonemic grain-sizes are important in Malay word recognition. Item analysis revealed a hierarchical pattern of difficulty based on the syllable and the phonic structure of the words. Error analysis identified the sources of errors to be errors due to inefficient syllable segmentation, oversimplification of syllables, insufficient grapheme-phoneme knowledge and inefficient phonemic code assembly. Evidence also suggests that direct instruction in syllable segmentation, phonemic awareness and grapheme-phoneme correspondence is necessary for low-progress readers to acquire word recognition skills. Finally, a logical sequence to teach grapheme-phoneme decoding in Malay is suggested. Copyright © 2010 John Wiley & Sons, Ltd.

  11. Water, Forests, People: The Swedish Experience in Building Resilient Landscapes.

    PubMed

    Eriksson, Mats; Samuelson, Lotta; Jägrud, Linnéa; Mattsson, Eskil; Celander, Thorsten; Malmer, Anders; Bengtsson, Klas; Johansson, Olof; Schaaf, Nicolai; Svending, Ola; Tengberg, Anna

    2018-07-01

    A growing world population and rapid expansion of cities increase the pressure on basic resources such as water, food and energy. To safeguard the provision of these resources, restoration and sustainable management of landscapes is pivotal, including sustainable forest and water management. Sustainable forest management includes forest conservation, restoration, forestry and agroforestry practices. Interlinkages between forests and water are fundamental to moderate water budgets, stabilize runoff, reduce erosion and improve biodiversity and water quality. Sweden has gained substantial experience in sustainable forest management in the past century. Through significant restoration efforts, a largely depleted Swedish forest has transformed into a well-managed production forest within a century, leading to sustainable economic growth through the provision of forest products. More recently, ecosystem services are also included in management decisions. Such a transformation depends on broad stakeholder dialog, combined with an enabling institutional and policy environment. Based on seminars and workshops with a wide range of key stakeholders managing Sweden's forests and waters, this article draws lessons from the history of forest management in Sweden. These lessons are particularly relevant for countries in the Global South that currently experience similar challenges in forest and landscape management. The authors argue that an integrated landscape approach involving a broad array of sectors and stakeholders is needed to achieve sustainable forest and water management. Sustainable landscape management-integrating water, agriculture and forests-is imperative to achieving resilient socio-economic systems and landscapes.

  12. Patient safety: lessons learned.

    PubMed

    Bagian, James P

    2006-04-01

    The traditional approach to patient safety in health care has ranged from reticence to outward denial of serious flaws. This undermines the otherwise remarkable advances in technology and information that have characterized the specialty of medical practice. In addition, lessons learned in industries outside health care, such as in aviation, provide opportunities for improvements that successfully reduce mishaps and errors while maintaining a standard of excellence. This is precisely the call in medicine prompted by the 1999 Institute of Medicine report "To Err Is Human: Building a Safer Health System." However, to effect these changes, key components of a successful safety system must include: (1) communication, (2) a shift from a posture of reliance on human infallibility (hence "shame and blame") to checklists that recognize the contribution of the system and account for human limitations, and (3) a cultivation of non-punitive open and/or de-identified/anonymous reporting of safety concerns, including close calls, in addition to adverse events.

  13. An Investigation into the Use of Computer-Assisted Instruction to Present Basic English Grammar Concepts

    DTIC Science & Technology

    1991-09-01

    involved in choosing hardware and so-ftware for CAI "are.the lesson objectives and the future needs of the instructor and student" (18:6-2). And...did not cover the graiTmatical errors nighlighted by the survey of subject-matter ’experts. Future research should include an expansion of, or...display any hypertext document. This tutorial covered basic English grammar concepts. Future research should address the possibilities of developing

  14. Diagnosing Diagnosis Errors: Lessons From A Multi-Institutional Collaborative Project

    DTIC Science & Technology

    2005-01-01

    Breast Cancer Inappropriately reassured to have benign lesions - 21/435 (5%); 14 (3%) misread mammogram, 4 (1%) misread pathologic finding, 5 (1...diagnostic tests they are using. It is well known that a normal mammogram in a woman with a breast lump does not rule out the diagnosis of breast cancer ...physician delay in the diagnosis of breast cancer . Arch Intern Med 2002;162:1343–8. 27. Clark S. Spinal infections go undetected. Lancet 1998;351

  15. Assessing Trauma Care Provider Judgement in the Prediction of Need for Life-saving Interventions

    DTIC Science & Technology

    2015-01-13

    suggest that agreement among groups of clinicians is far less dependable. The overall patterns of agreement among provider groups in our study are not...Gabbe BJ, Cameron P, Victorian State Trauma Outcomes Registry and Monitoring Group (VSTORM). Is paramedic judgement useful in prehospital trauma triage...2007;63:1338–46. [13] Gruen RL, Jurkovich GJ, McIntyre LK, Foy HM, Maier RV. Patterns of errors contributing to trauma mortality: lessons learned from

  16. An interlaboratory comparison of dosimetry for a multi-institutional radiobiological research project: Observations, problems, solutions and lessons learned.

    PubMed

    Seed, Thomas M; Xiao, Shiyun; Manley, Nancy; Nikolich-Zugich, Janko; Pugh, Jason; Van den Brink, Marcel; Hirabayashi, Yoko; Yasutomo, Koji; Iwama, Atsushi; Koyasu, Shigeo; Shterev, Ivo; Sempowski, Gregory; Macchiarini, Francesca; Nakachi, Kei; Kunugi, Keith C; Hammer, Clifford G; Dewerd, Lawrence A

    2016-01-01

    An interlaboratory comparison of radiation dosimetry was conducted to determine the accuracy of doses being used experimentally for animal exposures within a large multi-institutional research project. The background and approach to this effort are described and discussed in terms of basic findings, problems and solutions. Dosimetry tests were carried out utilizing optically stimulated luminescence (OSL) dosimeters embedded midline into mouse carcasses and thermal luminescence dosimeters (TLD) embedded midline into acrylic phantoms. The effort demonstrated that the majority (4/7) of the laboratories was able to deliver sufficiently accurate exposures having maximum dosing errors of ≤5%. Comparable rates of 'dosimetric compliance' were noted between OSL- and TLD-based tests. Data analysis showed a highly linear relationship between 'measured' and 'target' doses, with errors falling largely between 0 and 20%. Outliers were most notable for OSL-based tests, while multiple tests by 'non-compliant' laboratories using orthovoltage X-rays contributed heavily to the wide variation in dosing errors. For the dosimetrically non-compliant laboratories, the relatively high rates of dosing errors were problematic, potentially compromising the quality of ongoing radiobiological research. This dosimetry effort proved to be instructive in establishing rigorous reviews of basic dosimetry protocols ensuring that dosing errors were minimized.

  17. MANAGEMENT OF DIFFUSE POLLUTION IN AGRICULTURAL WATERSHEDS: LESSONS FROM THE MINNESOTA RIVER BASIN. (R825290)

    EPA Science Inventory

    Abstract

    The Minnesota River (Minnesota, USA) receives large non-point source pollutant loads. Complex interactions between agricultural, state agency, environmental groups, and issues of scale make watershed management difficult. Subdividing the basin's 12 major water...

  18. Current Fault Management Trends in NASA's Planetary Spacecraft

    NASA Technical Reports Server (NTRS)

    Fesq, Lorraine M.

    2009-01-01

    The key product of this three-day workshop is a NASA White Paper that documents lessons learned from previous missions, recommended best practices, and future opportunities for investments in the fault management domain. This paper summarizes the findings and recommendations that are captured in the White Paper.

  19. Iraq Reconstruction: Lessons in Contracting and Procurement

    DTIC Science & Technology

    2006-07-01

    January 4, 2006. 283. GAO report, “Federal Procurement: Spending and Workforce Trends,” GAO-03- 443, April 2003, p. 20. 284. Gloria Sochon and John ... Krieger , Presentation to the Government Contract Management Conference, December 5-6, 2005. 285. OMB memo, Deputy Director of Management to Chief

  20. Waste: A Hidden Resource.

    ERIC Educational Resources Information Center

    Keep America Beautiful, Inc., New York, NY.

    Corporations, government agencies, communities, and individuals are involved in waste management. Education about waste--where it comes from, how we dispose of it, and management alternatives--is needed. This document provides a series of educational resources which deal with these issues. Using these factsheets, lesson plans, lists of sources for…

  1. Tufts Health Sciences Database: Lessons, Issues, and Opportunities.

    ERIC Educational Resources Information Center

    Lee, Mary Y.; Albright, Susan A.; Alkasab, Tarik; Damassa, David A.; Wang, Paul J.; Eaton, Elizabeth K.

    2003-01-01

    Describes a seven-year experience with developing the Tufts Health Sciences Database, a database-driven information management system that combines the strengths of a digital library, content delivery tools, and curriculum management. Identifies major effects on teaching and learning. Also addresses issues of faculty development, copyright and…

  2. The effectiveness of the error reporting promoting program on the nursing error incidence rate in Korean operating rooms.

    PubMed

    Kim, Myoung-Soo; Kim, Jung-Soon; Jung, In Sook; Kim, Young Hae; Kim, Ho Jung

    2007-03-01

    The purpose of this study was to develop and evaluate an error reporting promoting program(ERPP) to systematically reduce the incidence rate of nursing errors in operating room. A non-equivalent control group non-synchronized design was used. Twenty-six operating room nurses who were in one university hospital in Busan participated in this study. They were stratified into four groups according to their operating room experience and were allocated to the experimental and control groups using a matching method. Mann-Whitney U Test was used to analyze the differences pre and post incidence rates of nursing errors between the two groups. The incidence rate of nursing errors decreased significantly in the experimental group compared to the pre-test score from 28.4% to 15.7%. The incidence rate by domains, it decreased significantly in the 3 domains-"compliance of aseptic technique", "management of document", "environmental management" in the experimental group while it decreased in the control group which was applied ordinary error-reporting method. Error-reporting system can make possible to hold the errors in common and to learn from them. ERPP was effective to reduce the errors of recognition-related nursing activities. For the wake of more effective error-prevention, we will be better to apply effort of risk management along the whole health care system with this program.

  3. Review: groundwater management practices, challenges, and innovations in the High Plains aquifer, USA—lessons and recommended actions

    NASA Astrophysics Data System (ADS)

    Sophocleous, Marios

    2010-05-01

    The US High Plains aquifer, one of the largest freshwater aquifer systems in the world, continues to decline, threatening the long-term viability of the region’s irrigation-based economy. The eight High Plains States take different approaches to the development and management of the aquifer based on each state’s body of water laws that abide by different legal doctrines, on which Federal laws are superposed, thus creating difficulties in integrated regional water-management efforts. Although accumulating hydrologic stresses and competing demands on groundwater resources are making groundwater management increasingly complex, they are also leading to innovative management approaches, which are highlighted in this paper as good examples for emulation in managing groundwater resources. It is concluded that the fragmented and piecemeal institutional arrangements for managing the supplies and quality of water are inadequate to meet the water challenges of the future. A number of recommendations for enhancing the sustainability of the aquifer are presented, including the formation of an interstate groundwater commission for the High Plains aquifer along the lines of the Delaware and Susquehanna River Basins Commissions in the US. Finally, some lessons on groundwater management that other countries can learn from the US experience are outlined.

  4. Decision Aids for Multiple-Decision Disease Management as Affected by Weather Input Errors

    USDA-ARS?s Scientific Manuscript database

    Many disease management decision support systems (DSS) rely, exclusively or in part, on weather inputs to calculate an indicator for disease hazard. Error in the weather inputs, typically due to forecasting, interpolation or estimation from off-site sources, may affect model calculations and manage...

  5. Lessons from 50 years of curing childhood leukaemia.

    PubMed

    Cole, Catherine Helen

    2015-01-01

    One of the great success stories of modern medicine is undoubtedly the remarkable improvement in outcome for childhood cancer, achieved through the work of the co-operative groups enrolling patients in randomised controlled trials. In 1965, survival was almost zero; now 5-year survival rates exceed 80% in high-income countries. The lessons learned in the care of patients with the most common malignancy in childhood--acute lymphoblastic leukaemia--have been used in all other cancers of childhood and more recently in the management of adults. These lessons can be broadly applied in medical practice, because elements of laboratory science in all branches of pathology, as well as a deep understanding of biochemistry, physiology, pharmacology, genetics and molecular science, run through this story. Far from being a sad area of practice, paediatric haematology and oncology remains the champion of embedded clinical and translational research, diagnosis from bench to bedside and lifelong multidisciplinary management of the child and their family. © 2015 The Author. Journal of Paediatrics and Child Health © 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians).

  6. Lessons learned from a regional strategy for resource allocation.

    PubMed

    Edwards, Janine C; Stapley, Jonathan; Akins, Ralitsa; Silenas, Rasa; Williams, Josie R

    2005-01-01

    Two qualitative case studies focus on the allocation of CDC funds distributed during 2002 for bioterrorism preparedness in two Texas public health regions (each as populous and complex as many states). Lessons learned are presented for public health officials and others who work to build essential public health services and security for our nation. The first lesson is that personal relationships are the cornerstone of preparedness. A major lesson is that a regional strategy to manage funds may be more effective than allocating funds on a per capita basis. One regional director required every local department to complete a strategic plan as a basis for proportional allocation of the funds. Control of communicable diseases was a central component of the planning. Some funds were kept at the regional level to provide epidemiology services, computer software, equipment, and training for the entire region. Confirmation of the value of this regional strategy was expressed by local public health and emergency management officials in a focus group 1 year after the strategy had been implemented. The group members also pointed out the need to streamline the planning process, provide up-to-date computer networks, and receive more than minimal communication. This regional strategy can be viewed from the perspective of adaptive leadership, defined as activities to bring about constructive change, which also can be used to analyze other difficult areas of preparedness.

  7. Ecological foundations of biodiversity: lessons from natural and managed forests of the Pacific Northwest.

    Treesearch

    Andrew B. Carey

    1998-01-01

    Fifteen years of research on old-growth and managed coniferous forests have provided sufficient understanding of biodiversity to suggest a basis for ecosystem management. First, natural old forests have a metaphysics values associated with their existence and function can never be addressed fully with the scientific method alone; we cannot recreate old growth. Second,...

  8. Integrating Environmental Management in Chemical Engineering Education by Introducing an Environmental Management System in the Student's Laboratory

    ERIC Educational Resources Information Center

    Montanes, Maria T.; Palomares, Antonio E.

    2008-01-01

    In this work we show how specific challenges related to sustainable development can be integrated into chemical engineering education by introducing an environmental management system in the laboratory where the students perform their experimental lessons. It is shown how the system has been developed and implemented in the laboratory, what role…

  9. Lessons from native spruce forests in Alaska: managing Sitka spruce plantations worldwide to benefit biodiversity and ecosystem services

    Treesearch

    Robert L. Deal; Paul Hennon; Richard O' Hanlon; David D' Amore

    2014-01-01

    There is increasing interest worldwide in managing forests to maintain or improve biodiversity, enhance ecosystem services and assure long-term sustainability of forest resources. An important goal of forest management is to increase stand diversity, provide wildlife habitat and improve forest species diversity. We synthesize results from natural spruce forests in...

  10. Being Student and Practitioner Centered: Lessons Learned from Integrating a Recreation Management Department into a Business School

    ERIC Educational Resources Information Center

    Freeman, Patti A.; Duerden, Mat D.; Hill, Brian J.

    2016-01-01

    In July 2009, Brigham Young University's Recreation Management (RecM) Department moved to the Marriott School of Management (MSM), beginning its integration into a nationally ranked business school, including the transition from a college with little coordination between departments to one where all majors share a common core of classes. Despite…

  11. Lessons Learned from the Clementine Mission

    NASA Technical Reports Server (NTRS)

    1997-01-01

    According to BMDO, the Clementine mission achieved many of its technology objectives during its flight to the Moon in early 1994 but, because of a software error, was unable to test the autonomous tracking of a cold target. The preliminary analyses of the returned lunar data suggest that valuable scientific measurements were made on several important topics but that COMPLEX's highest-priority objectives for lunar science were not achieved. This is not surprising given that the rationale for Clementine was technological rather than scientific. COMPLEX lists below a few of the lessons that may be learned from Clementine. Although the Clementine mission was not conceived as a NASA science mission exactly like those planned for the Discovery program, many operational aspects of the two are similar. It is therefore worthwhile to understand the strengths and faults of the Clementine approach. Some elements of the Clementine operation that led to the mission's success include the following: (1) The mission's achievements were the responsibility of a single organization and its manager, which made that organization and that individual accountable for the final outcome; (2) The sponsor adopted a hands-off approach and set a minimum number of reviews (three); (3) The sponsor accepted a reasonable amount of risk and allowed the project team to make the trade-offs necessary to minimize the mission's risks while still accomplishing all its primary objectives; and (4) The development schedule was brief and the agreed-on funding (and funding profile) was adhered to. Among the operational shortcomings of Clementine were the following: (1) An overly ambitious schedule and a slightly lean budget (meaning insufficient time for software development and testing, and leading ultimately to human exhaustion); and (2) No support for data calibration, reduction, and analysis. The principal lesson to be learned in this category is that any benefits from the constructive application of higher risk for lower cost and faster schedule will be lost if the schedule does not allow adequate time for the development of all essential systems or makes no allowance for human frailties. Another lesson to be drawn is that despite its limitations, if judged strictly as a science mission, Clementine attested that significant scientific information can be gathered during a technology-demonstration mission. In the current era of limited funds, when science missions will be infrequent, the opportunity to fly scientific instruments aboard missions whose objectives might be other than science must be seized and, indeed, encouraged. During such opportunities it would be inexcusable to do second-class science. Thus the scientific community must be actively involved in such projects from their initiation.

  12. Management of high-risk perioperative systems.

    PubMed

    Dain, Steven

    2006-06-01

    The perioperative system is a complex system that requires people, materials, and processes to come together in a highly ordered and timely manner. However, when working in this high-risk system, even well-organized, knowledgeable, vigilant, and well-intentioned individuals will eventually make errors. All systems need to be evaluated on a continual basis to reduce the risk of errors, make errors more easily recognizable, and provide methods for error mitigation. A simple approach to risk management that may be applied in clinical medicine is discussed.

  13. Data management, archiving, visualization and analysis of space physics data

    NASA Technical Reports Server (NTRS)

    Russell, C. T.

    1995-01-01

    A series of programs for the visualization and analysis of space physics data has been developed at UCLA. In the course of those developments, a number of lessons have been learned regarding data management and data archiving, as well as data analysis. The issues now facing those wishing to develop such software, as well as the lessons learned, are reviewed. Modern media have eased many of the earlier problems of the physical volume required to store data, the speed of access, and the permanence of the records. However, the ultimate longevity of these media is still a question of debate. Finally, while software development has become easier, cost is still a limiting factor in developing visualization and analysis software.

  14. Case Management of Dengue: Lessons Learned.

    PubMed

    Kalayanarooj, Siripen; Rothman, Alan L; Srikiatkhachorn, Anon

    2017-03-01

    The global burden of dengue and its geographic distribution have increased over the past several decades. The introduction of dengue in new areas has often been accompanied by high case-fatality rates. Drawing on the experience in managing dengue cases at the Queen Sirikit National Institute of Child Health in Bangkok, Thailand, this article provides the authors' perspectives on key clinical lessons to improve dengue-related outcomes. Parallels between this clinical experience and outcomes reported in randomized controlled trials, results of efforts to disseminate practice recommendations, and suggestions for areas for further research are also discussed. © The Author 2017. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.

  15. Managing human fallibility in critical aerospace situations

    NASA Astrophysics Data System (ADS)

    Tew, Larry

    2014-11-01

    Human fallibility is pervasive in the aerospace industry with over 50% of errors attributed to human error. Consider the benefits to any organization if those errors were significantly reduced. Aerospace manufacturing involves high value, high profile systems with significant complexity and often repetitive build, assembly, and test operations. In spite of extensive analysis, planning, training, and detailed procedures, human factors can cause unexpected errors. Handling such errors involves extensive cause and corrective action analysis and invariably schedule slips and cost growth. We will discuss success stories, including those associated with electro-optical systems, where very significant reductions in human fallibility errors were achieved after receiving adapted and specialized training. In the eyes of company and customer leadership, the steps used to achieve these results lead to in a major culture change in both the workforce and the supporting management organization. This approach has proven effective in other industries like medicine, firefighting, law enforcement, and aviation. The roadmap to success and the steps to minimize human error are known. They can be used by any organization willing to accept human fallibility and take a proactive approach to incorporate the steps needed to manage and minimize error.

  16. Analyzing human errors in flight mission operations

    NASA Technical Reports Server (NTRS)

    Bruno, Kristin J.; Welz, Linda L.; Barnes, G. Michael; Sherif, Josef

    1993-01-01

    A long-term program is in progress at JPL to reduce cost and risk of flight mission operations through a defect prevention/error management program. The main thrust of this program is to create an environment in which the performance of the total system, both the human operator and the computer system, is optimized. To this end, 1580 Incident Surprise Anomaly reports (ISA's) from 1977-1991 were analyzed from the Voyager and Magellan projects. A Pareto analysis revealed that 38 percent of the errors were classified as human errors. A preliminary cluster analysis based on the Magellan human errors (204 ISA's) is presented here. The resulting clusters described the underlying relationships among the ISA's. Initial models of human error in flight mission operations are presented. Next, the Voyager ISA's will be scored and included in the analysis. Eventually, these relationships will be used to derive a theoretically motivated and empirically validated model of human error in flight mission operations. Ultimately, this analysis will be used to make continuous process improvements continuous process improvements to end-user applications and training requirements. This Total Quality Management approach will enable the management and prevention of errors in the future.

  17. Innovations in Medication Preparation Safety and Wastage Reduction: Use of a Workflow Management System in a Pediatric Hospital.

    PubMed

    Davis, Stephen Jerome; Hurtado, Josephine; Nguyen, Rosemary; Huynh, Tran; Lindon, Ivan; Hudnall, Cedric; Bork, Sara

    2017-01-01

    Background: USP <797> regulatory requirements have mandated that pharmacies improve aseptic techniques and cleanliness of the medication preparation areas. In addition, the Institute for Safe Medication Practices (ISMP) recommends that technology and automation be used as much as possible for preparing and verifying compounded sterile products. Objective: To determine the benefits associated with the implementation of the workflow management system, such as reducing medication preparation and delivery errors, reducing quantity and frequency of medication errors, avoiding costs, and enhancing the organization's decision to move toward positive patient identification (PPID). Methods: At Texas Children's Hospital, data were collected and analyzed from January 2014 through August 2014 in the pharmacy areas in which the workflow management system would be implemented. Data were excluded for September 2014 during the workflow management system oral liquid implementation phase. Data were collected and analyzed from October 2014 through June 2015 to determine whether the implementation of the workflow management system reduced the quantity and frequency of reported medication errors. Data collected and analyzed during the study period included the quantity of doses prepared, number of incorrect medication scans, number of doses discontinued from the workflow management system queue, and the number of doses rejected. Data were collected and analyzed to identify patterns of incorrect medication scans, to determine reasons for rejected medication doses, and to determine the reduction in wasted medications. Results: During the 17-month study period, the pharmacy department dispensed 1,506,220 oral liquid and injectable medication doses. From October 2014 through June 2015, the pharmacy department dispensed 826,220 medication doses that were prepared and checked via the workflow management system. Of those 826,220 medication doses, there were 16 reported incorrect volume errors. The error rate after the implementation of the workflow management system averaged 8.4%, which was a 1.6% reduction. After the implementation of the workflow management system, the average number of reported oral liquid medication and injectable medication errors decreased to 0.4 and 0.2 times per week, respectively. Conclusion: The organization was able to achieve its purpose and goal of improving the provision of quality pharmacy care through optimal medication use and safety by reducing medication preparation errors. Error rates decreased and the workflow processes were streamlined, which has led to seamless operations within the pharmacy department. There has been significant cost avoidance and waste reduction and enhanced interdepartmental satisfaction due to the reduction of reported medication errors.

  18. Another Approach to Enhance Airline Safety: Using Management Safety Tools

    NASA Technical Reports Server (NTRS)

    Lu, Chien-tsug; Wetmore, Michael; Przetak, Robert

    2006-01-01

    The ultimate goal of conducting an accident investigation is to prevent similar accidents from happening again and to make operations safer system-wide. Based on the findings extracted from the investigation, the "lesson learned" becomes a genuine part of the safety database making risk management available to safety analysts. The airline industry is no exception. In the US, the FAA has advocated the usage of the System Safety concept in enhancing safety since 2000. Yet, in today s usage of System Safety, the airline industry mainly focuses on risk management, which is a reactive process of the System Safety discipline. In order to extend the merit of System Safety and to prevent accidents beforehand, a specific System Safety tool needs to be applied; so a model of hazard prediction can be formed. To do so, the authors initiated this study by reviewing 189 final accident reports from the National Transportation Safety Board (NTSB) covering FAR Part 121 scheduled operations. The discovered accident causes (direct hazards) were categorized into 10 groups Flight Operations, Ground Crew, Turbulence, Maintenance, Foreign Object Damage (FOD), Flight Attendant, Air Traffic Control, Manufacturer, Passenger, and Federal Aviation Administration. These direct hazards were associated with 36 root factors prepared for an error-elimination model using Fault Tree Analysis (FTA), a leading tool for System Safety experts. An FTA block-diagram model was created, followed by a probability simulation of accidents. Five case studies and reports were provided in order to fully demonstrate the usefulness of System Safety tools in promoting airline safety.

  19. Physiological responses to fertilization recorded in tree rings: isotopic lessons from a long-term fertilization trial - 2008

    EPA Science Inventory

    Nitrogen fertilizer applications are common land-use management tools, but details on physiological responses to these applications are often lacking, particularly for long-term responses over decades of forest management. We used tree-ring growth patterns and stable isotopes to...

  20. Management Challenges in an Information Communication Technology (ICT) Network in Rural Schools

    ERIC Educational Resources Information Center

    Mihai, Maryke; Nieuwenhuis, Jan

    2015-01-01

    This study concerns the management of an interactive whiteboard (IWB) network started in April 2008 in Mpumalanga, with a leading school partnered with several disadvantaged schools, transmitting lessons in Mathematics and Science. Many educational institutions try to provide learners with better learning opportunities by equipping schools with…

  1. Affective Teaching: A Method to Enhance Classroom Management

    ERIC Educational Resources Information Center

    Shechtman, Zipora; Leichtentritt, Judy

    2004-01-01

    The purpose of the study was to enhance classroom management in special education classrooms. "Affective teaching" was compared with "cognitive teaching" in 52 classrooms in Israel. Data was collected based on observations of three 90 minute lessons, equally divided into the two types of instruction. Results of MANOVA…

  2. Behavior Management: Examining the Functions of Behavior

    ERIC Educational Resources Information Center

    Alstot, Andrew E.; Alstot, Crystal D.

    2015-01-01

    Appropriate student behavior is essential for the success of a physical education lesson. Despite using effective proactive management strategies, teachers may need to also use reactive techniques to reduce problem behaviors by applying suitable consequences. For these consequences to be effective, they must be aligned with the function, or cause,…

  3. Managing Educator Talent: Promising Practices and Lessons from Midwestern States

    ERIC Educational Resources Information Center

    Bhatt, Monica P.; Behrstock, Ellen

    2010-01-01

    This policy analysis explains the need for a system approach to educator talent management. The report analyzes how state policies in the Midwest support the development of effective teachers and leaders throughout their career. The report focuses on state policies in teacher preparation including certification and licensure, recruitment and…

  4. The Way of the Gun: Applying Lessons of Ground Combat to Pilot Training

    DTIC Science & Technology

    2016-02-29

    actual practice repetitions.7 Current USAF Crew/Cockpit Resource Management ( CRM ) and Aerospace Physiology courses do not include any instruction on...Burke, Clint A. Bowers, and Katherine A. Wilson. Team Training in the Skies: Does Crew Resource Management ( CRM ) Training Work? Orlando, FL

  5. Backcountry impact management: Lessons from research

    Treesearch

    David N. Cole

    1994-01-01

    Recreational use of backcountry inevitably impacts environments intended for preservation. Where use is light or where management programs provide adequate protection, impacts need not be unacceptably severe. However, where use is heavy and protective actions are inadequate, impacts may be severe and widespread. Trails may become deeply eroded trenches or mudholes and...

  6. Improving Project Management Using Formal Models and Architectures

    NASA Technical Reports Server (NTRS)

    Kahn, Theodore; Sturken, Ian

    2011-01-01

    This talk discusses the advantages formal modeling and architecture brings to project management. These emerging technologies have both great potential and challenges for improving information available for decision-making. The presentation covers standards, tools and cultural issues needing consideration, and includes lessons learned from projects the presenters have worked on.

  7. Homeland Security Interagency Support. (Joint Center for Lessons Learned Quarterly Bulletin. Volume 4, Issue 2, March 2002)

    DTIC Science & Technology

    2002-03-01

    sections consists of four units, the Domestic Terrorism Operations Unit, the WMD Operations Unit, the WMD Countermeasures Unit, and Special Events Management Unit...Countermeasures Unit Chief Special Events Management Unit Chief Domestic Terrorism/ Counterterrorism Section Chief International Terrorism Section Asstistant

  8. Physiological responses to fertilization recorded in tree rings: Isotopic lessons from a long-term fertilization trial

    EPA Science Inventory

    Nitrogen fertilizer applications are common land use management tools, but details on physiological responses to these applications are often lacking, particularly for long-term responses over decades of forest management. We used tree ring growth patterns and stable isotopes to ...

  9. Assessing Leader Development: Lessons from a Historical Review of MBA Outcomes

    ERIC Educational Resources Information Center

    Passarelli, Angela M.; Boyatzis, Richard E.; Wei, Hongguo

    2018-01-01

    Graduate management education seeks to enhance the likelihood that graduates will be effective leaders, managers, or professionals. This requires programs that are designed to enable students to develop the related competencies, and increasing regulatory pressures require programs to document evidence of success. However, both the design of…

  10. Iraq Reconstruction: Lessons from Auditing U.S.-funded Stabilization and Reconstruction Activities

    DTIC Science & Technology

    2012-10-01

    Emergency Response Program: Hotel Construction Successfully Completed, but Project Management Issues Remain 09-025 7/26/2009 Commander’s Emergency...Emergency Response Pro- gram: Hotel Construction Completed, but Project Management Issues Remain,” 7/26/2009. 47. SIGIR Audit 11-003, “Iraqi Security Forces

  11. Using a Course Management System to Improve Classroom Communication

    ERIC Educational Resources Information Center

    Perkins, Matthew; Pfaffman, Jay

    2006-01-01

    Course management systems (CMSs) enable teachers to easily post assignments, lesson plans, announcements, and course documents. They also allow students to participate in online discussions and chats and turn in assignments online. Unfortunately, commercial systems are often expensive to purchase and maintain, removing them from the reach of many…

  12. Putting Patience to the Test

    NASA Technical Reports Server (NTRS)

    Morgan, Ray

    2004-01-01

    A project manager recounts his decisions before and during the aftermath of the crash of a full-size flying model of Quetzalcoatlus northropi. The unstable pterodactyl crashed without harming anyone, although it caused a local power outage. The manager summarizes lessons learned about flight testing prototypes, including the effects of impatience.

  13. School-Based Management and Arts Education: Lessons from Chicago

    ERIC Educational Resources Information Center

    Fitzpatrick, Kate R.

    2012-01-01

    School-based management, or local school control, is an organizational school reform effort aimed at decentralizing school decision-making that has become prevalent in districts throughout the United States. Using the groundbreaking Chicago system of local school control as an exemplar, this article outlines the implications of such reform efforts…

  14. Marketing Research. Instructor's Manual.

    ERIC Educational Resources Information Center

    Small Business Administration, Washington, DC.

    Prepared for the Administrative Management Course Program, this instructor's manual was developed to serve small-business management needs. The sections of the manual are as follows: (1) Lesson Plan--an outline of material covered, which may be used as a teaching guide, presented in two columns: the presentation, and a step-by-step indication of…

  15. Cycles for Science: Curriculum Supplement for Chemistry (Grades 9-12).

    ERIC Educational Resources Information Center

    Rogers, Diana, Ed.

    This document was developed in cooperation with secondary teachers and solid waste management professionals. The goal is to integrate steel recycling, natural resource conservation, and solid waste management into science learning. Basic concepts from the following chemistry units have been used to design the lessons and activities: transition…

  16. 77 FR 46113 - Proposed Information Collection; Comment Request; Cape Lookout National Park Visitor and...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-08-02

    ... data about visitors that can be used to prepare resource management planning documents. Lessons learned... Information Collection; Comment Request; Cape Lookout National Park Visitor and Community Survey AGENCY...) will ask the Office of Management and Budget (OMB) to approve the Information Collection (IC) described...

  17. Teach Like a Novice: Lessons from Beginning Teachers

    ERIC Educational Resources Information Center

    Eckert, Jonathan

    2014-01-01

    Classroom management is the greatest challenge for beginning teachers and continues to develop over their careers. Much can be learned from beginning teachers through reflection and the perspective that experience brings. Seven strategies can help improve classroom management: Maintain a growth mindset; try new ideas, reflect, then accept, reject,…

  18. Feeding & Management of Dairy Calves & Heifers. Teacher's Guide.

    ERIC Educational Resources Information Center

    Bjoraker, Walt

    This guide is designed to assist postsecondary and secondary teachers of agriculture in their use of the University of Wisconsin bulletin "Raising Dairy Replacements" in their dairy science instructional program. Eight lessons are provided in this unit: breeding decisions, management of cows from breeding to calving, care at calving time, the…

  19. Understanding Networking in China and the Arab World: Lessons for International Managers

    ERIC Educational Resources Information Center

    Hutchings, Kate; Weir, David

    2006-01-01

    Purpose: To explore the implications of internationalisation for "guanxi" and "wasta" and the role of trust, family and favours in underpinning these traditional models of networking. The paper also draws some implications for management development professionals and trainers. Design/methodology/approach: The argument is based…

  20. Small Business Management. Part I, A Suggested Course Outline.

    ERIC Educational Resources Information Center

    New York State Education Dept., Albany. Bureau of Continuing Education Curriculum Development.

    In this curriculum guide on small business management, lessons (including specific course content and teaching suggestions) are developed around general traits and practices conducive to success in small businesses, loans and other sources of capital, budgeting and planning, recordkeeping, marketing and selling, advertising and sales promotion,…

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