Jeffrey A Brinker, M.D.
- Professor of Medicine
- Joint Appointment in Radiology and Radiological Science
All human behavior buy gemfibrozil us definition of cholesterol crystal, good and bad cheap gemfibrozil line cholesterol foods eat, is reinforced gemfibrozil 300mg overnight delivery cholesterol test eating, whether by immediate consequences or by past experience. A behavior is reinforced by the consequences that an individual 19 experiences when the behavior occurs. The level of safety and reliability of a facility is directly dependent on the behavior of people. Because behavior is influenced by the consequences workers experience, what happens to workers when they exhibit certain behaviors is an important factor in improving human performance. Events can be avoided through an understanding of the reasons mistakes occur and application of the lessons learned from past events (or errors). Traditionally, improvement in human performance has resulted from corrective actions derived from an analysis of facility events and problem reports?a method that reacts to what happened in the past. Learning from our mistakes and the mistakes of others is reactive?after the fact?but important for continuous improvement. Human performance improvement today requires a combination of both proactive and reactive approaches. Anticipating how an event or error can be prevented is proactive and is a more cost-effective means of preventing events and problems from developing. Managing the Unexpected: Assuring High Performance in an Age of Complexity, 2001, Chapter 1; Longman, The Best Care Anywhere. Review of Findings for Human Error Contribution to Risk in Operating Events, 2001, p. Engineering Mentoring Program at Savannah River site highlighted a statistically significant correlation between personality profiles and Engineering Human Performance. Approximately 70 percent of the sample population was in the introverted/compliant/analytical? quadrant. These people tend to see things as more black and white, and have poor communication skills. While they view the work of others very critically, they tend to be defensive of criticism of their own work. It is precisely this part of human nature that we want to explore in the first part of this chapter. This inquiry includes discussions of human characteristics, unsafe attitudes, and at-risk behaviors that make people vulnerable to errors. A better understanding of what is behind the first principle of human performance, people are fallible, even the best make mistakes,? will help us better compensate for human error through more rigorous use of error-reduction tools and by improving controls. Certain sections of this chapter are considered essential reading and will be flagged as such at the beginning of the section. Unlike a machine that is precise?each time, every time?people are imprecise, especially in certain situations. Because of fallibility,? human beings are vulnerable to external conditions that cause them to exceed the limitations of human nature. Susceptibility to error is augmented when people work within complex systems (hardware or administrative) that have concealed weaknesses?latent conditions that either provoke error or weaken controls against the consequences of error. Common Traps of Human Nature People tend to overestimate their ability to maintain control when they are doing work. Maintaining control means that everything happens that is supposed to happen during performance of a task and nothing else. Second, there is a general lack of appreciation of the limits of human capabilities. For instance, many people have learned to function on insufficient rest or to work in the presence of enormous distractions or wretched environmental conditions (extreme heat, cold, noise, vibration, and so on). But, when the limits of human capabilities are exceeded (fatigue or loss of situational awareness, for example), the likelihood of error increases. The common characteristics of human nature addressed below are especially accentuated when work is performed in a complex work environment. Stress may result in more focused attention, which in some situations could actually be beneficial to performance. The problem with stress is that it can accumulate and overpower a person, thus becoming detrimental to performance. The important word is perceived; the perception one has about his or her ability to cope with the threat. Stress increases as familiarity with a situation 2-1 Department of Energy Human Performance Handbook Chapter 2 Reducing Error decreases. It can result in panic, inhibiting the ability to effectively sense, perceive, recall, think, or act. Anxiety and fear usually follow when an individual feels unable to respond successfully. Along with anxiety and fear, memory lapses are among the first symptoms to appear. The inability to think critically or to perform physical acts with accuracy soon follows. Humans are reluctant to engage in lengthy concentrated thinking, as it requires high levels of attention for extended periods. Consequently, people tend to look for familiar patterns and apply well-tried solutions to a problem. There is the temptation to settle for satisfactory solutions rather than continue seeking a better solution. The mental biases, or shortcuts, often used to reduce mental effort and expedite decision-making include:? Assumptions A condition taken for granted or accepted as true without verification of the facts. This bias orients the mind to see? evidence that supports the original supposition 2 and to ignore or rationalize away conflicting data.
- If you absolutely must be given such contrast, your doctor may give you antihistamines (such as Benadryl) or steroids before the test.
- Cholesterol test
- No cause for bleeding or other symptoms were found. Virtual colonoscopy can miss some smaller problems in the colon.
- Check for alertness. Shake or tap the infant gently. See if the infant moves or makes a noise. Shout, "Are you OK?"
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- You will usually be asked not to drink or eat anything for 6 to 12 hours before the procedure.
- Medicines to stop vomiting
Findings suggest that family based treatment is most effective for youth experiencing more severe symptoms of substance use purchase gemfibrozil amex cholesterol definition and importance. Home-based therapy included individual sessions with family members buy cheap gemfibrozil 300 mg online cholesterol en ratio, whereas office-based did not gemfibrozil 300 mg with amex cholesterol esterification definition. Significantly lower treatment refusal and higher engagement and treatment retention rates were found for those in the home-based family therapy group. However, compared with individual therapy, family intervention achieved higher rates of remission at 6 to 12 months follow-up (48% vs 33%). This meta-analysis did not include a report on within-group effectiveness for the two intervention types. Most sessions were held with the patient only, but eight additional 15-minute sessions were attended by both patient and parents. Substantial improvements were recorded on measures of eating disorder psychopathology and general psychiatric features. The intervention was delivered at an inpatient eating disorder unit and consisted of 20 weeks of treatment. Treatment was delivered in a range of formats including group, individual, family, and parent only. More than 85% of the cohort completed a follow-up assessment at 12 months, with the majority (82. However, compared with individual therapy, family intervention achieved higher rates of abstinence at 6 months follow-up (29% vs 16%). This meta-analysis did not contain information about within-group effectiveness for the two intervention types. Both interventions comprised up to 60 sessions across a 12-month period, consistent with usual treatment practice for bulimia nervosa in Germany. There was no significant difference between the treatment groups at posttreatment (33% vs 31%) and the outcomes were stable at 12 months, follow-up. However, at 12 months? follow-up, the difference between the two interventions was no longer significant (49% vs 32%). Overall, the family-based intervention for bulimia nervosa appears to be the preferred treatment for more rapid and sustained abstinence rates. Participants attended eight core sessions and four optional supplementary sessions on topics of interpersonal relations, behaviour activation, and emotional regulation. Parents attended an initial orientation session and were provided with psychoeducation about eating behaviours. Eleven of these studies targeted interventions for young children (0 to 5 years of age) and three focused on school-aged children and adolescents. The effects were not statistically significant at long term follow-up, although the authors noted that fewer studies incorporated follow-up assessments. For school-aged children (4 to 13 years of age), night waking duration was significantly reduced in the behavioural interventions group compared with pooled controls (small to medium effect size). Furthermore, school-aged children receiving a behavioural intervention achieved substantially higher sleep efficiency than did controls, accompanied by a large effect size. Fifteen participants completed the 6-month follow-up, and the same proportion (87%) no longer qualified for a delayed phase sleep disorder diagnosis. There were no differences detected between the two conditions on measures of total sleep time, waking after sleep onset, or depressive symptoms. Results were analysed separately for recurrent abdominal pain (n = 5), headaches/migraine (n = 2), and fibromyalgia (n = 2). However, in both studies children receiving hypnotherapy reported significantly less pain at posttreatment compared with controls. One study indicated a 67% reduction in pain days per month compared with 21% in controls, and the difference was significant both at posttreatment and 1-month follow-up. The second study indicated that pain intensity during a 1-week period was significantly reduced for the hypnotherapy group compared with controls. In the same study, treatment success at 12-month follow-up was determined to be 85% for hypnotherapy versus 25% for the control group, which was a significant result. These conclusions are consistent with the most recently published guidelines from the National Institute for Clinical Excellence (Obsessive-compulsive disorder and body dysmorphic disorder, 2005). These results were maintained at 2 months? follow-up and were accompanied by a large effect size. At the 12-month follow-up, 50% of the 26 participants were classified as responders and 23% as in remission. However, the authors noted that most patients continued to be symptomatic at 12 months, suggesting additional long-term treatment is warranted. All intervention types included combinations of individual, family, and group components. The intervention was delivered in an outpatient setting over 16 to 24 weeks and comprised one individual session and one family/group session per week. Across the 1-year period, within-group effect sizes for primary outcome measures ranged from medium (aggressive and delinquent behaviours) to large (depression, internalising behaviours, interpersonal sensitivity). Additionally, although two-thirds of participants had attempted suicide at least once prior to treatment, no suicide attempts were recorded during the treatment or follow-up period. Treatment focused on improving control over intense emotions and improving a broad range of coping skills. The intervention was delivered through 17 x 105-minute weekly group sessions as well as two booster sessions in the subsequent 12 weeks.
A depressed mood that is described as merely more severe order genuine gemfibrozil online cholesterol xanthelasma, longer lasting buy discount gemfibrozil 300 mg on-line cholesterol and vitamin d, or present without a reason is not considered distinct in quality gemfibrozil 300mg with mastercard cholesterol levels over 600. Melancholic features exhibit only a modest tendency to repeat across episodes in the same individual. They are more frequent in inpatients, as opposed to outpa? tients; are less likely to occur in milder than in more severe major depressive epi? sodes; and are more likely to occur in those with psychotic features. With atypical features: this specifier can be applied when these features predomi? nate during the majority of days of the current or most recent major depressive epi? sode. A long-standing pattern of interpersonal rejection sensitivity (not limited to epi? sodes of mood disturbance) that results in significant social or occupational impairment. Criteria are not met for with melancholic features? or with catatonia? during the same episode. Mood reactivity is the capacity to be cheered up when presented with positive events. Hypersomnia may include either an extended period of nighttime sleep or daytime napping that totals at least 10 hours of sleep per day (or at least 2 hours more than when not depressed). Unlike the other atypical features, pathological sensitivity to perceived inter? personal rejection is a trait that has an early onset and persists throughout most of adult life. With psychotic features: Delusions or hallucinations are present at any time in the episode. If psychotic features are present, specify if mood-congruent or mood-incon gruent: With mood-congruent psychotic features: During manic episodes, the con? tent of all delusions and hallucinations is consistent with the typical manic themes of grandiosity, invulnerability, etc. With mood-incongruent psychotic features: the content of delusions and hallucinations is inconsistent with the episode polarity themes as described above, or the content is a mixture of mood-incongruent and mood-congruent themes. With catatonia: this specifier can apply to an episode of mania or depression if cata? tonic features are present during most of the episode. See criteria for catatonia asso? ciated with a mental disorder in the chapter Schizophrenia Spectrum and Other Psychotic Disorders. Fifty percent of postpartum? major depressive episodes actually begin prior to delivery. Women with peripartum major depressive episodes often have severe anxiety and even panic attacks. Prospective studies have demonstrated that mood and anxiety symptoms during pregnancy, as well as the baby blues,? increase the risk for a postpartum major depressive episode. Peripartum-onset mood episodes can present either with or without psychotic features^ Infanticide is most often associated with postpartum psychotic episodes that are characterized by command hallucinations to kill the infant or delusions that the infant is possessed, but psychotic symptoms can also occur in severe postpar? tum mood episodes without such specific delusions or hallucinations. The risk of postpartum episodes with psychotic features is particularly increased for women with prior postpartum mood episodes but is also elevated for those with a prior history of a depressive or bipolar disorder (especially bipolar I disorder) and those with a family history of bipolar disorders. The postpar? tum period is unique with respect to the degree of neuroendocrine alterations and psychosocial adjustments, the potential impact of breast-feeding on treatment plan? ning, and the long-term implications of a history of postpartum mood disorder on sub? sequent family planning. With seasonal pattern: this specifier applies to the lifetime pattern of mood episodes. The essential feature is a regular seasonal pattern of at least one type of episode. For example, an individual may have seasonal manias, but his or her depressions do not regularly occur at a specific time of year. There has been a regular temporal relationship between the onset of manic, hypo manic, or major depressive episodes and a particular time of the year. Note: Do not include cases in which there is an obvious effect of seasonally related psychosocial stressors. Full remissions (or a change from major depression to mania or hypomania or vice versa) also occur at a characteristic time of the year. The essential feature is the onset and remission of major depressive episodes at char? acteristic times of the year. This pattern of onset and remission of episodes must have occurred during at least a 2-year period, without any nonseasonal episodes occurring during this period. This specifier does not apply to those situations in which the pattern is better ex? plained by seasonally linked psychosocial stressors. Major depressive episodes that occur in a seasonal pattern are often characterized by prominent energy, hypersomnia, overeating, weight gain, and a craving for carbohydrates. It is unclear whether a seasonal pattern is more likely in recurrent major depressive disorder or in bipolar disorders. Age is also a strong pre? dictor of seasonality, with younger persons at higher risk for winter depressive epi? sodes. Specify if: In partial remission: Symptoms of the immediately previous manic, hypomanie, or depressive episode are present, but full criteria are not met, or there is a period lasting less than 2 months without any significant symptoms of a manic, hypomanie, or major depressive episode following the end of such an episode. In full remission: During the past 2 months, no significant signs or symptoms of the disturbance were present. Mild: Few, if any, symptoms in excess of those required to meet the diagnostic criteria are present, the intensity of the symptoms is distressing but manageable, and the symptoms result in minor impairment in social or occupational functioning. Moderate: the number of symptoms, intensity of symptoms, and/or functional impair? ment are between those specified for mild?and severe. In order to address concerns about the potential for the overdiagnosis of and treatment for bipolar disorder in children, a new diagnosis, disruptive mood dysregulation disorder, referring to the presentation of children with persistent irritability and frequent episodes of extreme behavioral dyscontrol, is added to the depressive disorders for children up to 12 years of age. Its placement in this chapter reflects the finding that children with this symptom pattern typically develop unipolar depressive disorders or anxiety disorders, rather than bipolar disorders, as they mature into adolescence and adulthood. Major depressive disorder represents the classic condition in this group of disorders. A diagnosis based on a single episode is possible, although the disorder is a recurrent one in the majority of cases. Careful consid? eration is given to the delineation of normal sadness and grief from a major depressive ep? isode. Bereavement may induce great suffering, but it does not typically induce an episode of major depressive disorder.
Comparison of facility practices with the practices of other like operations that are considered best in class? is an ongoing effort order gemfibrozil with a visa cholesterol effects. The implementation of changes resulting from benchmarking should include an overall strategy to purchase gemfibrozil no prescription cholesterol chinese food disseminate the need gemfibrozil 300 mg fast delivery cholesterol test, urgency, methodology, and responsibilities for changing a facility process to match that of a benchmarked organization. Adopting a new process should be carried out with specific objectives in mind that are tied to eliminating identified weaknesses in the pre-existing process. They are tools to help managers focus actions on pressing issues in order to drive continuous improvement. The Pareto principle, or 80/20 rule, states that 80 percent of the consequences stem from 20 percent of the causes. This naturally occurring pattern helps identify the big hitters,? so that limited resources can be concentrated on resolving or improving the issues that comprise 80 percent (more or less) of all the problems. Once the big-hitter categories have been identified, analysts can plot each category over time, and they can then be addressed. Analysts can plot data over time for these categories to see how each category trends over time. Operating Experience There is a natural tendency for people to think It can?t happen here? or That won?t happen to me. The use of operating experience (using feedback acquired from previously operating equipment or a system, both internal and external to the facility) has proven effective in improving performance and keeping facilities safer. Operating experience helps ground individuals to the risks and vulnerabilities 3-20 Department of Energy Human Performance Handbook Chapter 3 Managing Defenses associated with specific activities. Operating experience is most effective when the right information is communicated to the right people in time to make a difference. Lessons learned can be reinforced during various training forums and through day-to-day activities such as pre-job briefings, coaching and reinforcement by supervisors, as well as through engineering design reviews. Managers routinely provide relevant operating experience information to workers at the time they have a need for it. The pre-job briefing is an excellent venue in which to share the operating experience. The challenge is to get workers to internalize the lessons learned and to apply them where appropriate to their upcoming job. Supervisors should ask individuals with key responsibilities in the work activity to explain how they will avoid specific errors committed in the events described. Supervision then considers appropriate controls to avoid or mitigate errors and the consequences suffered in the described event. Supervisors should elicit work history experiences from individuals experienced with the task and assigned to the present job. They will usually have pertinent information, notably about latent weaknesses that hampered previous job performance and what will prove very useful to the other assigned workers. Independent Oversight It is common for people to forget to be afraid of the risks and threats and to become complacent about latent weaknesses or flawed controls, especially when they are anxiously engaged day in and day out with their project or activities. Or, is it the absence of mindfulness,? the presence of a certain mindset,? or the existence of some unexplainable blind spots? How is it that an individual from another operation visiting in the facility can readily spot a process weakness, an unsafe practice, an error-likely situation, or a weakness in a defense that has gone unnoticed by resident workers and staff? It is because the outsider brings a fresh set of eyes, perceptions based on an ideal mental model of what should be and expectations that unencumbered by local culture, experience and constraints. It is exactly this disparity between insiders and independent observers in their ability to recognize degraded conditions that makes independent oversight such a powerful tool. Reviews of facility activities by outside organizations provide an opportunity to reveal blind spots? to facility management that otherwise would remain hidden or latent in the system. Analysts conducting root cause analysis of significant plant events should focus on what could have prevented the event rather than simply concentrating on who caused an event. It is also important to determine what controls worked to keep the event from being more severe. When causal analysis is fixated on individual culpability, finding effective corrective actions will be 22 elusive at best, as it is unlikely the analyst will identify the real causes of the event. An effective investigation focuses on discovering the latent weaknesses embedded in the organization, its culture, and the physical plant, rather than simply singling out one or two individuals for counseling or training. A root cause is the cause that, if corrected, will prevent recurrence of the event. Human error cannot be eliminated completely?inattention will continue to occur despite our best efforts to eliminate it. Hindsight predisposes the analyst to search for data that confirms the apparent shortcomings of the individual(s). Also, explaining what people could have or should have done explains nothing about why they did what they did. The challenge for the analyst is to determine why actions of the individuals made sense to them at the time. An analyst 23 can build that context by identifying the following for each individual:? This information is obtainable from the individuals involved, through interviews and by a review of the job-site conditions for each individual (procedures, recorder traces, logs, computer printouts, review of the workplace, equipment, and so forth). The answers to the bulleted questions become the starting point for further investigation into the causes of the event. The Anatomy of an Event model, introduced in Chapter 1, offers another structured approach to analyzing human performance issues. Working backward through the model from the event consequences to the organizational weaknesses that stimulated the event, helps explain the context of performance. Four major areas of fact need to be uncovered: (1) the specific consequences; (2) initiating actions (active errors) and error precursors that provoked the active errors; (3) flawed controls that either failed to prevent the active errors or failed to prevent or mitigate the event consequences; and (4) the organizational weaknesses that contributed to every 3-22 Department of Energy Human Performance Handbook Chapter 3 Managing Defenses 24 factor previously mentioned.
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Procedural memory refers to order gemfibrozil with a visa source of cholesterol in eggs our often unexplainable knowledge of how to buy 300 mg gemfibrozil visa cholesterol pregnancy do things order gemfibrozil 300 mg on-line cholesterol in eggs free range. When we walk from one place to another, speak to another person in English, dial a cell phone, or play a video game, we are using procedural memory. Procedural memory allows us to perform complex tasks, even though we may not be able to explain to others how we do them. There is no way to tell someone how to ride a bicycle; a person has to learn by doing it. The ability to crawl, walk, and talk are procedures, and these skills are easily and efficiently developed while we are children despite the fact that as adults we have no conscious memory of having learned them. A second type of implicit memory is classical conditioning effects, in which we learn, often without effort or awareness, to associate neutral stimuli (such as a sound or a light) with another stimulus (such as food), which creates a naturally occurring response, such as enjoyment or salivation. The memory for the association is demonstrated when the conditioned stimulus (the sound) begins to create the same response as the unconditioned stimulus (the food) did before the learning. The final type of implicit memory is known as priming, or changes in behavior as a result of experiences that have happened frequently or recently. One measure of the influence of priming on implicit memory is the word fragment test, in which a person is asked to fill in missing letters to make words. You can try this yourself: First, try to complete the following word fragments, but work on each one for only three or four seconds. I think you might find that it is easier to complete fragments 1 and 3 as library? and book,? respectively, after you read the sentence than it was before you read it. However, reading the sentence didn?t really help you to complete fragments 2 and 4 as physician? and chaise. Once a concept is primed it influences our behaviors, for instance, on word fragment tests. Research Focus: Priming Outside Awareness Influences Behavior One of the most important characteristics of implicit memories is that they are frequently formed and used automatically, without much effort or awareness on our part. In one demonstration of the automaticity and  influence of priming effects, John Bargh and his colleagues (Bargh, Chen, & Burrows, 1996) conducted a study in which they showed college students lists of five scrambled words, each of which they were to make into a sentence. Furthermore, for half of the research participants, the words were related to stereotypes of the elderly. These participants saw words such as the following: in Florida retired live people bingo man the forgetful plays the other half of the research participants also made sentences, but from words that had nothing to do with elderly stereotypes. The purpose of this task was to prime stereotypes of elderly people in memory for some of the participants but not for others. The experimenters then assessed whether the priming of elderly stereotypes would have any effect on the students? behavior?and indeed it did. When the research participant had gathered all of his or her belongings, thinking that the experiment was over, the experimenter thanked him or her for participating and gave directions to the closest elevator. Then, without the participants knowing it, the experimenters recorded the amount of time that the participant spent walking from the doorway of the experimental room toward the elevator. Automaticity of social behavior: Direct effects of trait construct and stereotype activation on action. To determine if these priming effects occurred out of the awareness of the participants, Bargh and his colleagues asked still another group of students to complete the priming task and then to indicate whether they thought the words they had used to make the sentences had any relationship to each other, or could possibly have influenced their behavior in any way. These students had no awareness of the possibility that the words might have been related to the elderly or could have influenced their behavior. Stages of Memory: Sensory, Short-Term, and Long-Term Memory Another way of understanding memory is to think about it in terms of stages that describe the length of time that information remains available to us. But not all information makes it through all three stages; most of it is forgotten. Whether the information moves from shorter-duration memory into longer-duration memory or whether it is lost from memory entirely depends on how the information is attended to and processed. Sensory memory is a memory buffer that lasts only very briefly and then, unless it is attended to and passed on for more processing, is forgotten. The purpose of sensory memory is to give the brain some time to process the incoming sensations, and to allow us to see the world as an unbroken stream of events rather than as individual pieces. In his research, Sperling showed participants a display of letters in rows, similar to that shown in Figure 8. Then, Sperling gave his participants a recall test in which they were asked to name all the letters that they could remember. On average, the participants could remember only about one-quarter of the letters that they had seen. He found that when he cued the participants to report one of the three rows of letters, they could do it, even if the cue was given shortly after the display had been removed. Sperling reasoned that the participants had seen all the letters but could remember them only very briefly, making it impossible for them to report them all. To test this idea, in his next experiment he first showed the same letters, but then after the display had been removed, he signaled to the participants to report the letters from either the first, second, or third row. In this condition, the participants now reported almost all the letters in that row. The short enough? is the length of iconic memory, which turns out to be about 250 milliseconds (? In contrast to iconic memories, which decay very rapidly, echoic memories can last as long as 4 seconds (Cowan, Lichty, & Grove,  1990). In some people iconic memory seems to last longer, a phenomenon known as eidetic imagery (or photographic memory?) in which people can report details of an image over long periods of time. These people, who often suffer from psychological disorders such as autism, claim that they can see? an image long after it has been presented, and can often report accurately on that image. There is also some evidence for eidetic memories in hearing; some people report that their echoic memories persist for unusually long periods of time. The composer Wolfgang Amadeus Mozart may have possessed eidetic memory for music, because even when he was very young and had not yet had a great deal of musical training, he could listen to long  compositions and then play them back almost perfectly (Solomon, 1995).