#synensis

[jcmarchi]

Improving patient safety using principles of aerospace engineering

New Post has been published on https://thedigitalinsider.com/improving-patient-safety-using-principles-of-aerospace-engineering/

Improving patient safety using principles of aerospace engineering

Approximately 13 billion laboratory tests are administered every year in the United States, but not every result is timely or accurate. Laboratory missteps prevent patients from receiving appropriate, necessary, and sometimes lifesaving care. These medical errors are the third-leading cause of death in the nation. 

To help reverse this trend, a research team from the MIT Department of Aeronautics and Astronautics (AeroAstro) Engineering Systems Lab and Synensys, a safety management contractor, examined the ecosystem of diagnostic laboratory data. Their findings, including six systemic factors contributing to patient hazards in laboratory diagnostics tests, offer a rare holistic view of this complex network — not just doctors and lab technicians, but also device manufacturers, health information technology (HIT) providers, and even government entities such as the White House. By viewing the diagnostic laboratory data ecosystem as an integrated system, an approach based on systems theory, the MIT researchers have identified specific changes that can lead to safer behaviors for health care workers and healthier outcomes for patients. 

A report of the study, which was conducted by AeroAstro Professor Nancy Leveson, who serves as head of the System Safety and Cybersecurity group, along with Research Engineer John Thomas and graduate students Polly Harrington and Rodrigo Rose, was submitted to the U.S. Food and Drug Administration this past fall. Improving the infrastructure of laboratory data has been a priority for the FDA, who contracted the study through Synensis.

Hundreds of hazards, six causes

In a yearlong study that included more than 50 interviews, the Leveson team found the diagnostic laboratory data ecosystem to be vast yet fractured. No one understood how the whole system functioned or the totality of substandard treatment patients received. Well-intentioned workers were being influenced by the system to carry out unsafe actions, MIT engineers wrote.  

Test results sent to the wrong patients, incompatible technologies that strain information sharing between the doctor and lab technician, and specimens transported to the lab without guarantees of temperature control were just some of the hundreds of hazards the MIT engineers identified. The sheer volume of potential risks, known as unsafe control actions (UCAs), should not dissuade health care stakeholders from seeking change, Harrington says. 

“While there are hundreds of UCAs, there are only six systemic factors that are causing these hazards,” she adds. “Using a system-based methodology, the medical community can address many of these issues with one swoop.” 

Four of the systemic factors — decentralization, flawed communication and coordination, insufficient focus on safety-related regulations, and ambiguous or outdated standards — reflect the need for greater oversight and accountability. The two remaining systemic factors — misperceived notions of risk and lack of systems theory integration — call for a fundamental shift in perspective and operations. For instance, the medical community, including doctors themselves, tends to blame physicians when errors occur. Understanding the real risk levels associated with laboratory data and HIT might prompt more action for change, the report’s authors wrote. 

“There’s this expectation that doctors will catch every error,” Harrington says. “It’s unreasonable and unfair to expect that, especially when they have no reason to assume the data they’re getting is flawed.”

Think like an engineer

Systems theory may be a new concept to the medical community, but the aviation industry has used it for decades. 

“After World War II, there were so many commercial aviation crashes that the public was scared to fly,” says Leveson, a leading expert in system and software safety. In the early 2000s, she developed the System-Theoretic Process Analysis (STPA), a technique based on systems theory that offers insights into how complex systems can become safer. Researchers used STPA in its report to the FDA. “Industry and government worked together to put controls and error reporting in place. Today, there are nearly zero crashes in the U.S. What’s happening in health care right now is like having a Boeing 787 crash every day.” 

Other engineering principles that work well in aviation, such as control systems, could be applied to health care as well, Thomas says. For instance, closed-loop controls solicit feedback so a system can change and adapt. Having laboratories confirm that physicians received their patients’ test results or investigating all reports of diagnostic errors are examples of closed-loop controls that are not mandated in the current ecosystem, Thomas says. 

“Operating without controls is like asking a robot to navigate a city street blindfolded,” Thomas says. “There’s no opportunity for course correction. Closed-loop controls help inform future decision-making, and, at this point in time, it’s missing in the U.S. health-care system.” 

The Leveson team will continue working with Synensys on behalf of the FDA. Their next study will investigate diagnostic screenings outside the laboratory, such as at a physician’s office (point of care) or at home (over the counter). Since the start of the Covid-19 pandemic, nonclinical lab testing has surged in the country. About 600 million Covid-19 tests were sent to U.S. households between January and September 2022, according to Synensys. Yet, few systems are in place to aggregate these data or report findings to public health agencies.  

“There’s a lot of well-meaning people trying to solve this and other lab data challenges,” Rose says. “If we can convince people to think of health care as an engineered system, we can go a long way in solving some of these entrenched problems.”

The Synensys research contract is art of the Systemic Harmonization and Interoperability Enhancement for Laboratory Data (SHIELD) campaign, an agency initiative that seeks assistance and input in using systems theory to address this challenge. 

[buntrousled]

(( if anyone wants to read the stabbening :> ))

[serafxn-a]

I CAN’T BELIEVE YOU KILLED A MICROWAVE

[tanezumi]

(( :>c ))

[bosspigeon]

playing WOW for the first time since college

named my Worgen priest Whorgen

[serafxn-a]

@synensis

Galaxy Bat Plushies and Stickers, by Brittany Zerkle on Etsy

See our ‘plush’ tag

[1postozagrad]

INCIJATIVA ZA SADNJU UZ PERGOLU U PARKU BARTOLA KAŠIĆA

Mjesni odbor Pavao Šubić

 Zagreb, 19. travnja 2022.

 Predmet: Sadnja penjačica na pergoli u parku Bartola Kašića

Poštovani/a,

          ovime molimo da se na postojećoj pergoli u sklopu dječjeg igrališta u parku Bartola Kašića zasade odgovarajuće biljke penjačice.

Postojeća pergola zamišljena je upravo za tu namjenu, no tamo ništa ne raste budući da nikad nije zasađeno i taj propust treba (konačno) ispraviti.

Utoliko molimo da se pergola popuni biljkama kako bi ispunila svoju ulogu, a biljke doprinijele boravišnim i ambijentalnim kvalitetama igrališta i parka, u prvome redu formiranjem potrebnoga hlada.

O vrsti ili vrstama biljaka trebaju odlučiti gradske stručne službe, a predlažemo da to bude glicinija (Wisteria synensis), budući da je upravo ta vrsta bila predviđena izvornim krajobraznim projektom parka. Oko vrste smo konzultirali autoricu krajobraznog projekta parka, prof.emeritu Branku Aničić, koja navodi da je uz svaki stup pergole bilo planirano posaditi po jednu sadnicu glicinije.

Ukoliko to nije moguće, alternativno predlažemo kivi ili jasmin.

Ova incijativa nije ni tehnički ni financijski zahtjevna, a može uvelike obogatiti predmetni park u kojem je postojeća pergola planirana za sadnju penjačica. Utoliko se nadamo da ćete incijativu podržati.

Na vašem ljubaznom angažmanu na poboljšanju Zagreba unaprijed zahvaljujemo.       

S poštovanjem,

 1POSTOZAGRAD

 1POSTOZAGRAD je građanska platforma usmjerena na poboljšanja grada i javna dobra. 1POSTOZAGRAD nije udruga, nema proračun niti raspolaže ikakvim sredstvima. Sav angažman na poboljšanjima Zagreba provodi se isključivo kroz počasni rad tj. volonterski.

Više: https://www.facebook.com/1postozagrad

[teahermitcomics]

Brand new wallpaper available now on my Patreon page! In high resolution, for your desktop or your wall. The theme is spring, so I wanted to illustrate my two best girls* in a flowery shojo homage. Hope you like it!

patreon.com/jadesarson

*If you don’t know them by now, these two are Geraldine from Cafe Suada, and Marie from For the Love of God, Marie!

[unseenbutnotgone]

I spent an entire day cranking out a flowchart for my RP friends that had trouble understanding the differences between all of our alternate muses. This sums up a lot of my Gaster’s affiliates’ information. It was a lot of fun to make, so maybe I will make more for other situations... feel free to send questions to me about any of this!

HELPFUL STORY LINKS: Detailed summary of the phases, Void and Nyala 1 2 3 4 5, Young UF Gaster, UF Gaster and Foreyes, Void and Oblivion 1 2 3 (flashing warning 3) 4 5 6, Wings and Reset 1 2..., Red Eye Theory and Updated RET.

KEY: [ ෦ ACTIVE RP BLOG] [ ↟ INACTIVE RP ARCHIVE] [ † “UNDERNET” RP BLOG]

VOID VERSE: 

Wings: unseenbutnotgone ෦, synensis †

Babyteeth: imbreaking-sans ෦ †

Cyprus: threeyearshopeful  ↟† 

Void: a-void-gaster  ↟, xa-eviterx †

Edgy: underfellsansrp  ↟, edgy-mc-lazy †

Chompy: papyrusthegreater-uf ↟, thin-red-line †

UNDERFALLEN VERSE:

Foureyes and UFN Gaster: ask-the-underfallen ↟

Mr. Audio: underfallenmraudio ↟, mraudio-the-audacious †

Twitchy: itsmybeautifullife  ↟, callmetwitchy †

Clawbite: crackedflowerpot †

OBLIVION VERSE: 

Oblivion: voided-oblivion ↟

Reset: seenbutgone ෦, setebcs  †

SCATTERED VERSE:

Scattered: scattered-core ↟, scattered-20xx †

[flapsinhands]

* THANK YOU...

* to be fair though, I do have to credit MOST of that to the time I've been stuck in the void but I like to think that still counts

* we talkin ages again

[hopxlcss]

✧ Dove

@synensis / @unseenbutnotgone  I would kill you. ✧ I would physically hurt you. ✧ I would attack you unprovoked. ✧ I would manipulate you. ✧ I dislike you. ✧ You annoy me. ✧ You scare me. ✧ You intimidate me. ✧ I hope I intimidate you. ✧ I pity you. ✧ You disgust me. ✧ I hate you. ✧ I’m indifferent toward you. ✧ I’d like to get to know you better. ✧   I’d like to spend more time with you. ✧ I’d like to be friends with you. ✧  I’m unsure what to think of you. ✧ I’m unsure how I feel about you. ✧ You are my friend. ✧ You are my best friend. ✧ You are my mentor. ✧ I look up to you. ✧ I respect you. ✧ You are my hero. ✧ You inspire me. ✧ You are my enemy. ✧ You make me happy. ✧ I want to protect you. ✧ I would fight by your side. ✧ I consider you an equal. ✧ I think you are beneath me. ✧ I think you are above me. ✧ I would lie for you. ✧ I would lie to you. ✧ I would sleep with you. ✧ I would sleep by your side. ✧ I would hug you. ✧ I would kiss you. ✧ You are family to me. ✧ I would die for you. ✧ I would kill for you. ✧ I would trust you with my life. ✧ I would trust you with my most precious belonging. ✧ I would trust you with a secret. ✧ I would trust you with my biggest / darkest secret. ✧ I love you (platonically). ✧ I love you (romantically).

[buntrousled]

ACTUALLY TO BE FAIR WINGS, YOU REBLOGGED A SUPERIOR VERSION, THE ONE I LAST SAW DIDN’T HAVE THOSE GIFS ON IT

[serafxn-a]

@setebcs @synensis @grxxnheart @unheardanduncaring

I FEEL LIKE ONE OF YOU GUYS IS RESPONSIBLE FOR THIS???

[unchcined]

W H I T E L I S T

@unheardanduncaring

@tanezumi

@synensis

[imcomedic-sans]

* @synensis

*...do you want a hug..?

[tanezumi]

@theseraph @flapsinhands @unheardanduncaring @grxxnheart @synensis @setebcs @hopxlcss I WILL FIGHT ALL OF YOU AT ONCE.