Background: When patients experience unexpected events, some health professionals become ''second victims''. These care givers feel as though they have failed the patient, second guessing clinical skills, knowledge base and career choice. Although some information exists, a complete understanding of this phenomenon is essential to design and test supportive interventions that achieve a healthy recovery. Methods: The purpose of this article is to report interview findings with 31 second victims. After institutional review board approval, second victim volunteers representing different professional groups were solicited for private, hourlong interviews. The semistructured interview covered demographics, participant recount of event, symptoms experienced and recommendations for improving institutional support. After interviews, transcripts were analyzed independently for themes, followed by group deliberation and reflective use with current victims. Results: Participants experienced various symptoms that did not differ by sex or professional group. Our analysis identified six stages that delineate the natural history of the second victim phenomenon. These are (1) chaos and accident response, (2) intrusive reflections, (3) restoring personal integrity, (4) enduring the inquisition, (5) obtaining emotional first aid and (6) moving on. We defined the characteristics and typical questions second victims are desperate to have answered during these stages. Several reported that involvement in improvement work or patient safety advocacy helped them to once again enjoy their work. Conclusions: We now believe the post-event trajectory is largely predictable. Institutional programs could be developed to successfully screen at-risk professionals immediately after an event, and appropriate support could be deployed to expedite recovery and mitigate adverse career outcomes. BACKGROUND
The curriculum led to changes in second-year medical students' knowledge, skills, and attitudes, but not all of the changes were sustained at one year, were in the desired direction, or were supported by their self-reported behaviors. The extent to which other informal or hidden curriculum experiences reversed the gains and affected the changes at one year is unknown.
We demonstrate the creation of entangled, spin-squeezed states using a collective, or joint, measurement and real-time feedback. The pseudospin state of an ensemble of N = 5 × 10 4 laser-cooled 87 Rb atoms is deterministically driven to a specified population state with angular resolution that is a factor of 5.5(8) [7.4(6) dB] in variance below the standard quantum limit for unentangled atomscomparable to the best enhancements using only unitary evolution. Without feedback, conditioning on the outcome of the joint premeasurement, we directly observe up to 59(8) times [17.7( 6) dB] improvement in quantum phase variance relative to the standard quantum limit for N = 4 × 10 5 atoms. This is one of the largest reported entanglement enhancements to date in any system.
Collective measurements can project a system into an entangled state with enhanced sensitivity for measuring a quantum phase, but measurement backaction has limited previous efforts to only modest improvements. Here we use a collective measurement to produce and directly observe, with no background subtraction, an entangled, spin-squeezed state with phase resolution improved in variance by a factor of 10.5(1.5), or 10.2(6) dB, compared to the initially unentangled ensemble of N = 4.8 × 10 5 87 Rb atoms. The measurement uses a cavity-enhanced probe of an optical cycling transition to mitigate back-action associated with state-changing transitions induced by the probe. This work establishes collective measurements as a powerful technique for generating entanglement for precision measurement, with potential impacts in biological sensing, communication, navigation, and tests of fundamental physics.A defining characteristic of quantum mechanics is the ability of a measurement to change the state of the system being measured. For example, a measurement of a system in a super-1 arXiv:1310.3177v1 [quant-ph] 11 Oct 2013 position of two states causes the system to project, or collapse, into one of the two discrete states. Measurements performed on an ensemble, however, can project the ensemble into an entangled state when only collective quantities are measured. For instance, here we measure a cavity field that is entangled with the total number of spin-1/2 atoms in spin up (Fig. 1A). Any information about the spin-state of a single atom that leaks to the environment due to imperfections in the collective measurement reduces entanglement due to collapse of individual atoms.Such collective or joint measurements arise in a wide range of applications, including quantum teleportation (1), quantum information protocols (2), studies of strongly-correlated quantum systems (3), Dicke superradiance (4), and entanglement generation in optical (5), solid state (6) and atomic systems (7).Entanglement generated by a collective measurement can be used to overcome the fundamental quantum randomness that limits a diverse set of precision measurements (8). Atomic sensors in particular are nearly or already limited by quantum noise, so entanglement-enhanced metrology would improve some of the most precise measurements of external fields (9), rotations (10), and time (11), and will advance searches for new physics (12). Atomic sensors encode their information in a quantum phase θ, whose value is estimated by measuring the population of atoms in different quantum states. Quantum projection noise (13) for an ensemble of N independent atoms limits the uncertainty in the estimate of θ to a variance ∆θ 2 ≥ ∆θ 2 SQL = 1/N , a limit known as the standard quantum limit (SQL) for a coherent spin state (CSS). Entanglement can be used to bypass this limitation in atomic sensors, as well as in microwave (14) and optical (15) fields.A collective measurement that both resolves the quantum noise that appears in θ and induces sufficiently small measuremen...
Problem: Although morbidity and mortality conferences (MMCs) are meant to promote quality care through careful analysis of adverse events, focus on individual actions or the fear of incrimination may interfere with identification of system issues contributing to the adverse outcomes. Design: Participant attitudes before and after the intervention towards patient safety and conference redesign were assessed using an attitudinal survey. A list of contributing factors, recommended solutions and targeted system improvements was maintained with ongoing progress recorded. Setting: Department of Internal Medicine training programme at University of Missouri-Columbia. Participants: Residents and fellows from the above residency programme. Educational objectives: (1) Distinguish between culture of blame/shame and patient safety culture, (2) identify gaps in quality contributing to adverse outcomes (3) identify strategies to close gaps and (4) participate in root cause analysis, demonstrating an ability to review an adverse event and recommend an action plan. Strategies for change: An interdisciplinary team modified the internal medicine MMC to emphasise a better understanding of patient safety principles and system-based practice interventions. For each adverse event analysed, root causes were identified, followed by discussion of system interventions that might prevent future such events. Key measures for improvement: (1) Attitudes of residents and fellows regarding patient safety, as measured on a 20-item, five-point ordinal scale survey, (2) system improvements generated from the patient safety MMC (PSMMC) and (3) attendance at PSMMC. Effects of change: Clinical outcomes: 121 system improvement recommendations were made and 39 were pursued on the basis of likelihood of achieving high impact changes. 23 improvements were implemented, 11 were partially implemented or in progress, and 5 were abandoned due to impracticality or redundancy. Educational outcomes: 58 residents and fellows completed surveys before and after modification of conference format. 6/20 survey items showed substantial change with four of these changes occurring in the desired direction. Eleven of the remaining 14 responses changed in the desired direction. Average MMC attendance increased from 41¡8 to 50¡10 participants (p,0.03). Lessons learnt: The new PSMMC initiated multiple improvements in the quality of patient care without sacrificing attendance or attitudes of the residents or fellows. The new PSMMC promotes opportunities for participants to improve quality of patient care in a safe and nurturing environment.
BackgroundResearch evidence underpins best practice, but is not always used in healthcare. The Promoting Action on Research Implementation in Health Services (PARIHS) framework suggests that the nature of evidence, the context in which it is used, and whether those trying to use evidence are helped (or facilitated) affect the use of evidence. Urinary incontinence has a major effect on quality of life of older people, has a high prevalence, and is a key priority within European health and social care policy. Improving continence care has the potential to improve the quality of life for older people and reduce the costs associated with providing incontinence aids.ObjectivesThis study aims to advance understanding about the contribution facilitation can make to implementing research findings into practice via: extending current knowledge of facilitation as a process for translating research evidence into practice; evaluating the feasibility, effectiveness, and cost-effectiveness of two different models of facilitation in promoting the uptake of research evidence on continence management; assessing the impact of contextual factors on the processes and outcomes of implementation; and implementing a pro-active knowledge transfer and dissemination strategy to diffuse study findings to a wide policy and practice community.Setting and sampleFour European countries, each with six long-term nursing care sites (total 24 sites) for people aged 60 years and over with documented urinary incontinenceMethods and designPragmatic randomised controlled trial with three arms (standard dissemination and two different programmes of facilitation), with embedded process and economic evaluation. The primary outcome is compliance with the continence recommendations. Secondary outcomes include proportion of residents with incontinence, incidence of incontinence-related dermatitis, urinary tract infections, and quality of life. Outcomes are assessed at baseline, then at 6, 12, 18, and 24 months after the start of the facilitation interventions. Detailed contextual and process data are collected throughout, using interviews with staff, residents and next of kin, observations, assessment of context using the Alberta Context Tool, and documentary evidence. A realistic evaluation framework is used to develop explanatory theory about what works for whom in what circumstances.Trial registrationCurrent Controlled Trials ISRCTN11598502.
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