Harmful Events Research Articles

The role of health locus of control and spiritual well-being on elderlies’ meaning of life

ABSTRACT Spirituality, as one of the fundamental concepts in life is an important factor in adapting to the consequences of aging and providing mental health for the elderly. Meaning of life acts as a shock absorber against the stress. This study aims to determine the role of health locus of control and spiritual well-being on meaning in life of the elderly people. In this descriptive–analytical study, through structural equation modeling, 300 elderly people from Birjand were selected in 2017 and entered into the study by multi-stage cluster sampling method. The findings showed that among the components of health locus of control, the internal health and health related to the powerful others could predict the elderlies’ meaning of life. Regarding the components of spiritual well-being, existential health had the potential to predict the meaning of life among the elderly. Finally, internal health had a significant effect on spiritual well-being, and spiritual well-being had a significant effect on the meaning of life in elderlies. Thus, we can promote the elderlies’ control over events of life, increase their purposefulness, and consequently help them to cope with the specific harmful events of the elderly age by providing appropriate programs and conducting behavioral interventions.

"The way I see it makes me believe you intentionally did it": Intentionality ascription and gaze transition entropy in violent offenders.

Cognitive processes underlying inferences regarding inferring mental states (i.e. intentionality ascription) are still to be investigated. To assess how people accumulate social cues in order to attribute intentionality, a measure of gaze transition entropy (GTE) seems indicated to throw some light on these processes. Violent behavior is associated with distorted attributional processes but also with deficiencies in attention to socially relevant cues. Therefore, the current study compared the level of entropy between both violent male and female offenders and non-offenders and explore the association between GTE and ascribing intentionality. The sample (N = 128) consisted of violent inmates (N=63, 31 women) and adults living in the community (N=65, 31 women). Lower entropy characterized violent offenders to a greater extent as compared to those with no history of volent crimes. Moreover, lower entropy predicted greater intentionality ascription especially in judging ambiguous and hostile harmful events but only in the violent offender group. Findings imply that hostile attributions in violent offenders not only depend on a predisposition to interpret external reality in a hostile manner but can be the result of an inferential processing based on insufficient and incomplete information.

Fish Kills Related to Harmful Algal Bloom Events in Southeast Asia

Fish kills in Southeast Asia are frequently associated with harmful algal blooms (HABs) and cause significant ecological and economic impacts and can have negative effects on the sustainability of aquatic ecosystems and the fisheries they support. This paper serves as a review of fish-kill events with focus on those related to HABs within the region. It examines the causative algal species, known mechanisms of fish mortality, and socio-economic consequences in order to better understand and manage this threat to sustainable fisheries. Fish kills have been reported across multiple countries within Southeast Asia, with notable hotspots in the Philippines, Malaysia, Singapore, Indonesia, and Thailand. The common harmful microalgal species span a diverse group including dinoflagellates (Karenia spp., Karlodinium spp., Margalefidinium polykrikoides, Noctiluca scintillans), raphidophytes (Chattonella spp.), diatoms (Skeletonema spp. and Chaetoceros spp.), and cyanobacteria (Trichodesmium spp.). These microalgae lead to fish kills through mechanisms such as hypoxia, physical gill damage, and ichthyotoxin production. Freshwater fish kills linked to HABs have also been documented for the Philippines, but there is no or limited information for the region. Our review highlights the widespread and recurring nature of fish kills, their impact on fisheries and aquaculture, and challenges in managing and mitigating their effects. There are efforts at enhancing management and mitigation using clay and early warning systems. However, it is essential to further improve monitoring efforts, the development and deployment of early warning systems, and viable and holistic mitigation strategies to protect the region’s aquatic resources and dependent communities, especially as aquaculture and coastal development are increasing concurrent with a changing climate that can exacerbate the risks of fish kills and HABs in Southeast Asia.

Implementation of a Standardized Tool for Root Cause Analysis Selection.

This study sought to determine if a standardized root cause analysis (RCA2) selection algorithm, developed by the Veterans Affairs, would select high-risk events for RCA. Physician-entered incident reports for all surgical service admissions and perioperative visits were queried over 12 months in the DATIX Clinical Incident Management System. Independent reviewers assigned potential harm and event frequency scores using an institutional scoring system and then calculated and rounded average scores. These were classified using RCA2 terminology (catastrophic, major, moderate, minor for harm; frequent, occasional, uncommon, remote for frequency). The scores were then evaluated with the standardized Safety Assessment Code Matrix (SAC) algorithm from the National Patient Safety Foundation's RCA2 guidelines to determine Potential Harm Scores. The SAC combines severity and probability to determine the necessity of conducting an RCA. Catastrophic and major high-frequency events (matrix score = 3) were classified as "RCA recommended." The study then compared cases selected for RCAs using the updated RCA2 algorithm against cases selected using a current, institutional-specific RCA selection process. One hundred four cases were reviewed, comprising 20 catastrophic, 48 major harm, 26 moderate harm, and 10 minor harm events. After removing 9 high-variance cases, our institution's current selection process selected 18 cases for RCAs, including 6/20 catastrophic, 8/39 major harm, and 4/36 moderate/minor harm events. Only 17.3% of cases had an RCA completed, while the standardized RCA2 algorithm recommended investigation for 56.7% of patient safety events, based on SAC Matrix scoring. Current RCA selection processes rendered 4 RCAs on low potential harm or low-frequency events, while 45 potential high-frequency, high potential harm events did not complete RCAs. Standardizing the selection of patient safety incidents for RCA using the RCA2 algorithm improves case identification based on the event frequency and potential harm score. Thus, this algorithm has the potential to advance patient safety.

What is known about near miss events in the operating room? A systematic review of studies of mixed methods design.

A near miss event (NME) in healthcare is an event that did not happen but would have caused serious harm if it did. The operating room (OR) is prone to risk and incidents, with estimates that 50% of all hospital adverse events occur in the OR, yet reporting of NME is uncommon in the OR. To carry out a systematic review of studies with mixed methods to establish what is known about NME reporting in the OR. Inclusion criteria will be those studies of mixed methods design, which have been conducted in the OR, with teams of surgeons, anaesthetists or nurses alone or in any combination. Using a publication timeframe of 2001-2023, the following databases were searched: Medline (OVID), CINAHL, Pubmed and Google Scholar. Selected papers for the review were assessed using the Quality Assessment Tool for Studies of Diverse Designs. Fourteen papers were included in the review. NMEs are common occurrences that are underreported in the OR. When NMEs occur in multiples for the same patient, the risk of serious harm increases. Feedback and education about NME helps to improve reporting; ORs with high rates of NME reporting have less serious patient harm events. The implications of the findings for improving healthcare safety are discussed and in particular the adoption of the science of Human Factors Ergonomics into healthcare.

A Composite Score Reflecting an Initiative to Reduce Harm, Protect Patients, and Promote Safety.

Since 2011, hospitals in the United States have used the Total Harm Rate as a metric to address and enhance patient safety by mitigating harmful events. However, upon evaluation, it was concluded that this tool had lost its validity and was not widely used as an effective measure to prevent harm to patients. There are no similar comparative data in the literature to which we can compare our results with others. The Quality Management Performance Improvement team began to develop a composite safety score that would be used to reflect the environment of patient safety and promote improvement opportunities.

Perspectives on Anesthesia and Perioperative Patient Safety: Past, Present, and Future.

During the past 70 years, patient safety science has evolved through four organizational frameworks known as Safety-0, Safety -1, Safety-2, and Safety-3. Their evolution reflects the realization over time that blaming people, chasing errors, fixing one-offs, and regulation would not create the desired patient safety. In Safety-0, the oldest framework, harm events arise from clinician failure; event prevention relies on better staffing, education, and basic standards. In Safety-1, used by hospitals, harm events arise from individual and/or system failures. Safety is improved through analytics, workplace culture, high reliability principles, technology, and quality improvement. Safety-2 emphasizes clinicians' adaptability to prevent harm events in an everchanging environment, using resilience engineering principles. Safety-3, used by aviation, adds system design and control elements to Safety-1 and Safety-2, deploying human factors, design-thinking, and operational control or feedback to prevent and respond to harm events. Safety-3 represents a potential way for anesthesia and perioperative care to become safer.

Improving NSAID Safety: The Role of Transdermal Ketoprofen in the Management of Musculoskeletal Pain and Inflammation

Pain and inflammation affect patients both acutely and chronically across all patient demographics. Often, the medications which are used to target musculoskeletal conditions are poorly tolerated due to various contraindications, drug interactions, and troublesome adverse events. The investigation and development of localized, externally applied NSAIDs is on the rise among researchers and pharmaceutical manufacturers, but research is still inefficient in determining the role in therapy of transdermal analgesics and anti-inflammatories. Compounding Pharmacies and FDA 503b Outsourcing Facilities aid in this critical endeavor through endogenous compounding and manufacturing (respectively) of transdermal analgesic formulations. This review summarizes the currently available data supporting the implementation of transdermal ketoprofen preparations in the management of musculoskeletal pain and inflammation. Externally applied NSAIDs are crucial in the development of pain management modalities which reduce the risk of numerous complications, including drug-drug interactions, conflicting comorbidities, and harmful systemic adverse events.

Exploring the Role of Reactive Oxygen Species in the Pathogenesis and Pathophysiology of Alzheimer's and Parkinson's Disease and the Efficacy of Antioxidant Treatment.

Alzheimer's (AD) and Parkinson's Disease (PD) are life-altering diseases that are characterised by progressive memory loss and motor dysfunction. The prevalence of AD and PD is predicted to continuously increase. Symptoms of AD and PD are primarily mediated by progressive neuron death and dysfunction in the hippocampus and substantia nigra. Central features that drive neurodegeneration are caspase activation, DNA fragmentation, lipid peroxidation, protein carbonylation, amyloid-β, and/or α-synuclein formation. Reactive oxygen species (ROS) increase these central features. Currently, there are limited therapeutic options targeting these mechanisms. Antioxidants reduce ROS levels by the induction of antioxidant proteins and direct neutralisation of ROS. This review aims to assess the effectiveness of antioxidants in reducing ROS and neurodegeneration. Antioxidants enhance major endogenous defences against ROS including superoxide dismutase, catalase, and glutathione. Direct neutralisation of ROS by antioxidants protects against ROS-induced cytotoxicity. The combination of Indirect and direct protective mechanisms prevents ROS-induced α-synuclein and/or amyloid-β formation. Antioxidants ameliorate ROS-mediated oxidative stress and subsequent deleterious downstream effects that promote apoptosis. As a result, downstream harmful events including neuron death, dysfunction, and protein aggregation are decreased. The protective effects of antioxidants in human models have yet to directly replicate the success seen in cell and animal models. However, the lack of diversity in antioxidants for clinical trials prevents a definitive answer if antioxidants are protective. Taken together, antioxidant treatment is a promising avenue in neurodegenerative disease therapy and subsequent clinical trials are needed to provide a definitive answer on the protective effects of antioxidants. No current treatment strategies have significant impact in treating advanced AD and PD, but new mimetics of endogenous mitochondrial antioxidant enzymes (Avasopasem Manganese, GC4419 AVA) may be a promising innovative option for decelerating neurodegenerative progress in the future at the mitochondrial level of OS.

Effect of low climate impact vs. high climate impact inhalers for patients with asthma and COPD-a nationwide cohort analysis

BackgroundChronic obstructive pulmonary disease (COPD) and asthma can be treated with inhaled corticosteroids (ICS) delivered by low climate impact inhalers (dry powder inhalers) or high climate impact inhalers (pressurized metered-dose inhalers containing potent greenhouse gasses). ICS delivered with greenhouse gasses is prescribed ubiquitously and frequent despite limited evidence of superior effect. Our aim was to examine the beneficial and harmful events of ICS delivered by low and high climate impact inhalers in patients with asthma and COPD.MethodsNationwide retrospective cohort study of Danish outpatients with asthma and COPD treated with ICS delivered by low and high climate impact inhalers. Patients were propensity score matched by the following variables; age, gender, tobacco exposure, exacerbations, dyspnoea, body mass index, pulmonary function, ICS dose and entry year. The primary outcome was a composite of hospitalisation with exacerbations and all-cause mortality analysed by Cox proportional hazards regression.ResultsOf the 10,947 patients with asthma and COPD who collected ICS by low or high climate impact inhalers, 2,535 + 2,535 patients were propensity score matched to form the population for the primary analysis. We found no association between high climate impact inhalers and risk of exacerbations requiring hospitalization and all-cause mortality (HR 1.02, CI 0.92–1.12, p = 0.77), nor on pneumonia, exacerbations requiring hospitalization, all-cause mortality, or all-cause admissions. Delivery with high climate impact inhalers was associated with a slightly increased risk of exacerbations not requiring hospitalization (HR 1.10, CI 1.01–1.21, p = 0.03). Even with low lung function there was no sign of a superior effect of high climate impact inhalers.ConclusionLow climate impact inhalers were not inferior to high climate impact inhalers for any risk analysed in patients with asthma and COPD.

Exploring variations in patient safety events across equity-deserving populations

The objective of this analysis was to examine variations in rates of hospital harm (HH), an important indicator of patient safety events, across population subgroups in Canada. We conducted a descriptive study of HH in provinces and territories using three years (2016 to 2018) of CIHI’s Discharge Abstract Database (DAD) linked to the 2016 Canadian Census, also known as Statistics Canada’s Canadian Census Health and Environment Cohorts (CanCHEC). We investigated the influence of sociodemographic variables not generally available in hospital administrative data. We calculated age-standardized rates (ASR) per 100 hospital discharges and 95% confidence intervals for HH, stratified by sex, income (area and individual), racialized group, education, immigration status, language, disability status, social and material deprivation, and geography (urban vs. rural/remote). Despite males experiencing higher rates of harm (ASR 4.36 vs. 4.23), overall females experienced 54% of all HH events, with an average age of 64 (vs age 49 for those discharged without a HH event). For neighbourhood income quintile, the highest rates of HH were observed in the lowest quintile (4.08, 4.04 – 4.11). The rate of HH decreased as neighbourhood income increased. Patients from rural/remote neighbourhoods had lower rates of HH (3.7, 3.66-3.73) than those living in urban neighbourhoods (4.47, 4.44-4.49). Additional equity-stratified results will be presented. Our analysis revealed that marginalized populations were more likely to experience a harmful event during their hospital stay. Measuring and monitoring inequalities in patient safety provides health systems with information to better understand, target, and evaluate healthcare quality improvement initiatives.

The Role of Cyano-HAB (Cyanobacteria Harmful Algal Blooms) in the One Health Approach to Global Health

Harmful algal bloom events occur in salt, brackish, and fresh water. In bodies of water such as oceans and estuaries, diatoms or dinoflagellates form “tides” that produce toxins associated with seafood poisoning, including paralytic shellfish poisoning, or respiratory distress from inhalation of aerosolized toxins. Cyanobacteria predominantly bloom in fresh water; they can produce microcystins; cylindrospermopsin; and other toxins that humans or animals might be exposed to through water contact, inhalation, or ingestion. Animals that become ill or die can be sentinels for harmful algal bloom events. In a One Health approach, information about harmful algal bloom exposures and health effects support efforts to detect these events and mitigate and prevent associated illnesses. Human, animal, and environmental health partners can work together to document the occurrence and impacts of harmful algal bloom events and characterize associated illnesses.

Redox imbalance and metabolic defects in the context of Alzheimer disease.

Redox reactions play a critical role for intracellular processes, including pathways involved in metabolism and signaling. Reactive oxygen species (ROS) act either as second messengers or generators of protein modifications, fundamental mechanisms for signal transduction. Disturbance of redox homeostasis is associated with many disorders. Among these, Alzheimer's disease is a neurodegenerative pathology that presents hallmarks of oxidative damage such as increased ROS production, decreased activity of antioxidant enzymes, oxidative modifications of macromolecules, and changes in mitochondrial homeostasis. Interestingly, alteration of redox homeostasis is closely associated with defects of energy metabolism, involving both carbohydrates and lipids, the major energy fuels for the cell. As the brain relies exclusively on glucose metabolism, defects of glucose utilization represent a harmful event for the brain. During aging, a progressive perturbation of energy metabolism occurs resulting in brain hypometabolism. This condition contributes to increase neuronal cell vulnerability ultimately resulting in cognitive impairment. The current review discusses the crosstalk between alteration of redox homeostasis and brain energy defects that seems to act in concert in promoting Alzheimer's neurodegeneration.

Are yessotoxins an emerging problem in Chile? Context and perspectives following the first report of YTX levels exceeding the regulatory limit in the Patagonian fjord system

In late summer and early autumn 2022, an intense bloom of Protoceratium reticulatum—the main yessotoxin (YTX) producer along Chilean coasts and a major threat to artisanal fisheries, the aquaculture industry, and environmental health—was recorded in the Patagonian fjord system. The high YTX levels (>3.75 mg kg−1) resulted in the first ban of shellfish collection in Chile. At Puyuhuapi Fjord, a global "hotspot" of harmful algal bloom events, the cell density of P. reticulatum determined in integrated tube samples (0–10 m) at the end of April 2022 reached 407,000 cells L−1. At the same time, YTX levels well exceeded the regulatory limit by roughly 2.5-fold, with concentrations as high as 9.42 mg kg−1 measured in native populations of the blue mussel Mytilus chilensis. Five different YTX analogues, 45-OH-YTX, COOH-45-keto-YTX, COOH-45-OH-YTX, COOH-YTX, and 45,55-diOH-YTX, were also detected in relevant amounts. While the ban lasted close to 3 months, accumulation and detoxification processes were monitored over a 1-year period. This study assessed the implications of high levels of YTXs and their analogues on the local economy and ecosystem health, given the increase in P. reticulatum blooms predicted for NW Patagonia in the context of a changing climate.

Treatment of Menstrual Irregularities with Individualized Homeopathic Medicinal Products in Early Reproductive Females: A Double-Blind, Randomized, Placebo-Controlled Trial.

Objectives: Prevalence of irregular menstrual cycle ranges from 81.7% to 96.3%. Recent research suggested that homeopathy is one of the most popular choices for women with various gynecological disorders. This trial was aimed at differentiating individualized homeopathic medicinal products (IHMPs) from identical-looking placebos in the treatment of menstrual irregularities in early reproductive women. Design: Double-blind, randomized (1:1), two parallel arms, placebo-controlled trial. Setting: D. N. De Homoeopathic Medical College & Hospital, Kolkata, West Bengal, India. Subjects: Ninety-two females with menstrual irregularities. Interventions: Group verum (n = 46; IHMPs plus concomitant care) versus group control (n = 46; placebos plus concomitant care). Outcome Measures: Primary-The proportion of early reproductive females in whom menstrual irregularities can be corrected for consecutive three cycles; Secondary-Menstrual Distress Questionnaire (MDQ) total score; all of them were measured at baseline and every month, up to 4 months. Results: Intention-to-treat sample (n = 92) was analyzed. Group differences were examined by chi-squared tests with categorical outcomes, two-way repeated measure analysis of variance accounting for the time-effect interactions, and unpaired t-tests comparing the mean estimates obtained individually every month. The level of significance was set at p < 0.05 two-tailed. After 4 months of intervention, the group difference in the primary outcome was nonsignificant statistically-IHMPs: 22/46 v/s placebo: 24/46, chi-square (Yates corrected) = 0.043, p = 0.835. The improvement observed in the MDQ total score (F1,90 = 0.054, p = 0.816) and subscales scores were higher in the IHMPs group than in placebos, however statistically nonsignificant in most of the occasions, except for the behavioral change subscale (F1,90 = 0.029, p < 0.001). Pulsatilla nigricans was the most frequently prescribed medicine. Kent's Repertory and Zandvoort's Complete Repertory were the most frequently used repertories. No harm or serious adverse events were reported from either group. Conclusions: The analysis failed to demonstrate clearly that IHMPs were effective beyond placebos in all but one of the outcomes. More appropriate outcome measures may be sought for future trials. Clinical Trial Registration Number: CTRI/2022/04/041659.

Lessons for an invisible future from an invisible past: Risk and resilience in deep time

The interrelated concepts of risk and resilience are inherently future-focused. Two main dimensions of risk are the probability that a harmful event will happen in the future and the probability that such an event will cause a varying degree of loss. Resilience likewise refers to the organization of a biological, societal, or technological system such that it can withstand deleterious consequences of future risks. Although both risk and resilience pertain to the future, they are assessed by looking to the past – the past occurrence of harmful events, the losses incurred in these events, and the success or failure of systems to mitigate loss when these events occur. Most common risk and resilience measures rely on records extending a few decades into the past at most. However, much longer-term dynamics of risk and resilience are of equal if not greater importance for the sustainability of coupled socioecological systems which dominate our planet. Historical sciences, including archeology, are critical to assessing risk and resilience in deep time to plan for a sustainable future. The challenge is that both past and future are invisible; we can directly observe neither. We present examples from recent archeological research that provide insights into prehistoric risk and resilience to illustrate how archeology can meet this challenge through large-scale meta-analyses, data science, and modeling.

Concept analysis of patient journey disruptions: the obstacle of integrated care

PurposeThis article aims to clarify the concepts used to understand, analyze and improve a patient’s progress through a health service system. A patient pathway describes plans and intentions. Within it, we distinguish between the clinical pathway of decisions and interventions and the care pathway of supportive activities. As a patient pathway is implemented, it turns into a patient journey of what is done, what happens to a patient’s medical condition and what is experienced and felt. We introduce “patient journey disruption” (PJD) as a concept describing the events that need to be prevented from happening to accomplish integrated, coordinated and seamless care.Design/methodology/approachThe method used in this paper is concept analysis. First, an expert steering group worked to refine the concept of PJDs; second, an analysis of similar concepts from related fields was done to root the concept into existing theories, and third, semi-structured interviews with professionals and patients were done to test the concept of PJDs in the home care context.FindingsPJDs are agency-based harmful events in the execution of the care pathway that deviate the patient journey from what can be reasonably expected. PJDs are management failures, which is why they should be studied by healthcare operations management (HOM) and service science scholars with the intention to find ways to prevent them from happening.Research limitations/implicationsThis study has limitations, including presenting conceptual ideas and preliminary results that are only indicative.Practical implicationsWe believe that the introduction of the concept of PJDs into the literature provides a new, systematic way of approaching the different shortcomings in our healthcare production systems. Moreover, by systematically identifying different PJDs, interventions can be designed and targeted more appropriately.Originality/valueManagerial challenges regarding healthcare processes have been studied but have not been well defined. The concept of PJDs is an original, well-thought-out definition.

Patient Harm Events and Associated Cost Outcomes Reported to a Patient Safety Organization.

The aims of the study were to describe inpatient harm events detected via an automatic electronic trigger system (ETS) and to consider their financial consequences. Over a 27-month period, inpatient harm events were identified and documented in 1 healthcare system with 37 acute care facilities. Patients who experienced harm (all harm or preventable harm only) were compared with similar patients who did not. Clinical, financial, and demographic data were used to identify labor-adjusted direct variable costs (DVC) and potential differences in length of stay (LOS) associated with all-harm, preventable-harm, and nonharmed cohorts. Age-adjusted Charlson Comorbidity Index, case mix index, diagnosis-related groups, major diagnostic category, sex, age, location, diagnosis, adverse event category and subcategory, preventability, and harm severity were used to compare cohorts. Total harm events reported via the ETS and the health system's voluntary event reporting system were compared. Nearly 93,000 encounters for all-harm (n = 25,665) and nonharmed cohorts (n = 67,217) were compared by random sampling of diagnosis-related group-matched all-harm and nonharmed groups to ensure similar clinical conditions, as measured by Charlson Comorbidity Index and case mix index. Sampling (2 groups, n = 100 and n = 200) showed that increased LOS was associated with harm; yet other clinical comparators were similar across groups. the preventable-harm subcohort had longer LOS (10.7 versus 5.9 days) and higher DVC ($13,442 versus $8024) than the nonharmed cohort. Identification of harm events was nearly 6-fold higher with the ETS than with the voluntary event reporting system. Patients with preventable harm had increased LOS that was associated with higher DVC per preventable-harm encounter in a large US healthcare system.

Evaluation of the Ghanaian Healthcare Environment and Patient Safety context using the SEIPS model of Work System

Objective: This paper aimed to evaluate hazards contributing to patient safety incidents within Ghana’s healthcare system using a human factors engineering model to trace risks across interacting domains. Methods: The Systems Engineering Initiative for Patient Safety (SEIPS) model framed analysis of challenges within the dimensions of healthcare Personnel, Tasks, Tools/Technology, Environment, Organization and Processes. Over 25 studies provided multi-dimensional empirical evidence, with insights synthesized across domains to depict risk pathways enabling patient harm events. Conclusions: The analysis reveals a severely overburdened and constrained healthcare ecosystem unable to reliably deliver safe care processes – with risks stemming from financing limitations, infrastructure deficits, equipment failures, health worker shortages and skills gaps, supply variability, leadership prioritization, and information systems. Solutions require coordinated commitment across these interdependent aspects. Recommendations: Six priority actions are proposed spanning governance, culture, staffing, health IT, quality programs and financing – grounded in concrete evidence-based initiatives but connected through systems thinking. Significance: This systems analysis substantially advances understanding of patient safety threats in Ghana to motivate action. The model approach further demonstrates application of human factors engineering methods to diagnose healthcare quality challenges in limited-resource settings.

Probabilistic method for risk analysis of unintentional islanding of distributed generators

Unintentional islanding can be a harmful event, requiring the fast actuation of the anti-islanding protection to disconnect the distributed generators. Although passive techniques are mostly used, they have non-detection zones and fail to detect islanding under specific conditions. Therefore, knowing in advance such operative conditions and the risks associated with the islanding occurrence can be a strategic information to support grid operators in the decision-making process regarding the effectiveness of distributed generators interconnection protection. In this context, this paper proposes a probabilistic method to assess the risk of energized island formation by combining the probability of breaker (or recloser) opening with the probability of anti-islanding protection failure. The method employs probabilistic short circuit associated with overcurrent protection actuation by using Monte Carlo simulation and time-domain analysis to obtain the cases of unintentional islanding and to calculate the risk of distributed generator islanded operation. The results drove more realistic and less conservative conclusions than previous literature. Additionally, it is shown that faults as the cause of breaker opening do play a relevant role in the performance of the anti-islanding protection.