A Framework for the Analysis of Communication Errors in Health Care.

Objectives: The goal of this study was to develop a systematic method to identify and classify different types of communication failures leading to patient safety events. We aimed to develop a taxonomy code sheet for identifying communication errors and provide a framework tool to classify the communication error types.

Methods: This observational study used the Delphi method to develop a taxonomy code sheet for identifying communication errors reported in the Veterans Health Administration patient safety databases between April 2018 and March 2021.

Hemodialysis Bleeding Events and Deaths: An 18-Year Retrospective Analysis of Patient Safety and Root Cause Analysis Reports in the Veterans Health Administration.

Objectives: Eighteen years of patient safety (PS) and root cause analysis reports for hemodialysis bleeding events and deaths in the Veterans Health Administration were analyzed with dual purpose: to determine the impact of a 2008 Veterans Health Administration Patient Safety Advisory on event reporting rates and to identify actions to mitigate risk and inform policy.

Methods: From 2002 to 2020, 281 bleeding events (248 PS reports and 33 root cause analyses) including 14 deaths during hemodialysis treatments were identified. Events were characterized by the type of vascular access, patient mental status, and whether the access site was visible or obscured from view by staff.

Silicon Quantum Dot-Polymer Fabry-Pérot Resonators with Narrowed and Tunable Emissions.

Luminescent silicon nanoparticles have been widely recognized as an alternative for metal-based quantum dots (QDs) for optoelectronics partly because of the high abundance and biocompatibility of silicon. To date, the broad photoluminescence line width (often >100 nm) of silicon QDs has been a hurdle to achieving competitive spectral purity and incorporating them into light-emitting devices. Herein we report fabrication and testing of straightforward configuration of Fabry-Pérot resonators that incorporates a thin layer of SiQD-polymer hybrid/blend between two reflective silver mirrors; remarkably these devices exhibit up-to-14-fold narrowing of SiQD emission and achieve a spectral bandwidth as narrow as ca.

Cardiac Telemetry Downtime and Contingency Plan Development: A Review of Downtime Events Reported in the Veterans Health Administration.

Background: Cardiac telemetry downtime may be planned or unplanned, causing a disruption in telemetry services with a potential to impact patient safety.

Problem: Many cardiac telemetry units in the Veterans Health Administration (VHA) have contingency plans that do not adequately address telemetry downtime.

Approach: This is a retrospective quality improvement analysis of VHA-reported cardiac telemetry downtime events from October 1, 2014, to Mar 31, 2020.

Diagnostic Neuroradiology Subspecialty Training: 1 Versus 2 Years; the Canadian Perspective.

Background: Canada began a national reform of its post-graduate medical education training programs to a Competence By Design (CBD) model. Trends from accredited neuroradiology programs from the past 10 years were investigated to inform educators and stakeholders for this process.

Methods: A 13-question electronic survey was sent to program directors of all 8 accredited neuroradiology training programs in Canada.

A Novel Parameter to Predict Supraclinoid Aneurysm Persistence After Flow Diversion with the Pipeline Embolization Device.

Background: Aneurysm recurrence after Pipeline Embolization Device (PED) placement can be caused by oversizing of the stent as well as poor wall apposition, both of which can lead to elongation. The objective of this study was to assess whether a novel parameter for measuring device elongation based on two-dimensional imaging could be predictive for persistent aneurysm filling after treatment with the PED.

Methods: A retrospective cohort analysis was initially completed on 41 aneurysms from institution A, examining demographic, aneurysmal, and device measurements.

Patient Misidentification Events in the Veterans Health Administration: A Comprehensive Review in the Context of High-Reliability Health Care.

Objectives: The Veterans Health Administration maintains national patient safety event reporting and root cause analysis (RCA) databases. These were reviewed to understand the prevalence of and provide insight into patient misidentification. The results were compared with a high-reliability health care framework.

Functional lasing microcapillaries for surface-specific sensing.

Lasing-based sensors have several advantages over fluorescent devices, specifically related to the high light intensity and narrow mode linewidth that can improve the speed and accuracy of the sensor performance. In this work, a microcapillary-based lasing sensor is demonstrated, in which the lasing wavelengths are sensitive to the surface binding of specific materials. In order to achieve this, we utilized lasing into the "star" and "triangle" modes of a conventional microcapillary and tracked the mode positions after the deposition of a polyelectrolyte tri-layer and the subsequent amide binding of carboxy-functionalized polystyrene microspheres.

Wide-gamut lasing from a single organic chromophore.

The development of wideband lasing media has deep implications for imaging, sensing, and display technologies. We show that a single chromophore can be engineered to feature wide-gamut fluorescence and lasing throughout the entire visible spectrum and beyond. This exceptional color tuning demonstrates a chemically controlled paradigm for light emission applications with precise color management.

Reappraising the Luminescence Lifetime Distributions in Silicon Nanocrystals.

The luminescence dynamics in ensembles of nanocrystals are complicated by a variety of processes, including the size-dependence of the radiative and non-radiative rates in inhomogeneous broadened samples and interparticle interactions. This results in a non-exponential decay, which for the specific case of silicon nanocrystals (SiNCs) has been widely modeled with a Kohlrausch or "stretched exponential" (SE) function. We first derive the population decay function for a luminescence decay following exp[- (t/τ)].

Refractometric micro-sensor using a mirrored capillary resonator.

We report on a flow-through optical sensor consisting of a microcapillary with mirrored channels. Illuminating the structure from the side results in a complicated spectral interference pattern due to the different cavities formed between the inner and outer capillary walls. Using a Fourier transform technique to isolate the desired channel modes and measure their resonance shift, we obtain a refractometric detection limit of (6.

Rapid delayed growth of ruptured supraclinoid blister aneurysm after successful flow diverting stent treatment.

A 62-year-old woman presented with a subarachnoid hemorrhage secondary to a ruptured right supraclinoid internal carotid artery blister aneurysm. She was treated in an emergent fashion with two flow diverting pipeline embolization devices (PED) deployed in a telescoping fashion. CT angiography performed for unrelated reasons at 7 months showed successful treatment of the aneurysm without evidence of residual aneurysm.

Rapid delayed growth of ruptured supraclinoid blister aneurysm after successful flow diverting stent treatment.

A 62-year-old woman presented with a subarachnoid hemorrhage secondary to a ruptured right supraclinoid internal carotid artery blister aneurysm. She was treated in an emergent fashion with two flow diverting pipeline embolization devices (PED) deployed in a telescoping fashion. CT angiography performed for unrelated reasons at 7 months showed successful treatment of the aneurysm without evidence of residual aneurysm.

Clinical utility of a screening protocol for blunt cerebrovascular injury using computed tomography angiography.

OBJECTIVE Blunt cerebrovascular injury (BCVI) occurs in approximately 1% of the blunt trauma population and may lead to stroke and death. Early vascular imaging in asymptomatic patients at high risk of having BCVI may lead to earlier diagnosis and possible stroke prevention. The objective of this study was to determine if the implementation of a formalized asymptomatic BCVI screening protocol with CT angiography (CTA) would lead to improved BCVI detection and stroke prevention.

Neuroradiology Using Secure Mobile Device Review.

Background: Image review on computer-based workstations has made film-based review outdated. Despite advances in technology, the lack of portability of digital workstations creates an inherent disadvantage. As such, we sought to determine if the quality of image review on a handheld device is adequate for routine clinical use.

Characteristics of patients with diabetes who accept referrals for care management services.

Introduction: Patients with chronic conditions can improve their health through participation in self-care programs. However, awareness of and enrollment in these programs are generally low.

Objective: We sought to identify factors influencing patients' receptiveness to a referral for programs and services supporting chronic disease management.

The Frequency of Subarachnoid Hemorrhage from Very Small Cerebral Aneurysms (< 5 mm): A Population-Based Study.

Background:  The prevailing view amongst neurosurgeons is that the larger the aneurysm, the higher the chance of rupture. This implies that very small aneurysms rarely rupture. To investigate this theory, we conducted a cross-sectional hospital-based study of aneurysmal subarachnoid hemorrhage, with an emphasis on aneurysm size at the time of rupture.

Temporal Changes in Periprocedural Events in the Carotid Revascularization Endarterectomy Versus Stenting Trial.

Background And Purpose: Post-hoc, we hypothesized that over the recruitment period of the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST), increasing experience and improved patient selection with carotid stenting, and to a lesser extent, carotid endarterectomy would contribute to lower periprocedural event rates.

Methods: Three study periods with approximately the same number of patients were defined to span recruitment. Composite and individual rates of periprocedural stroke, myocardial infarction, and death rate were calculated separately by treatment assignment (carotid stenting/carotid endarterectomy).

Evolving role of MRI in optimizing the treatment of multiple sclerosis: Canadian Consensus recommendations.

Background: Magnetic resonance imaging (MRI) is increasingly important for the early detection of suboptimal responders to disease-modifying therapy for relapsing-remitting multiple sclerosis. Treatment response criteria are becoming more stringent with the use of composite measures, such as no evidence of disease activity (NEDA), which combines clinical and radiological measures, and NEDA-4, which includes the evaluation of brain atrophy.

Methods: The Canadian MRI Working Group of neurologists and radiologists convened to discuss the use of brain and spinal cord imaging in the assessment of relapsing-remitting multiple sclerosis patients during the treatment course.

Can the Windkessel Hypothesis Explain Delayed Intraparenchymal Haemorrhage After Flow Diversion? A Case Report and Model-Based Analysis of Possible Mechanisms.

Background: Delayed ipsilateral intraparenchymal haemorrhage is a recently recognised complication after endovascular flow diversion for intracranial aneurysms. Although the mechanism of this phenomenon is not understood, one proposed explanation (the windkessel hypothesis) is that removal of aneurysmal compliance increases distal pulse pressure.

Methods: We present a case of delayed haemorrhage after placement of a Pipeline stent, discuss the proposed mechanisms, and describe a novel electrical analogue model that was used to evaluate the likely haemodynamic effect of stent placement.

Randomized assessment of rapid endovascular treatment of ischemic stroke.

Background: Among patients with a proximal vessel occlusion in the anterior circulation, 60 to 80% of patients die within 90 days after stroke onset or do not regain functional independence despite alteplase treatment. We evaluated rapid endovascular treatment in addition to standard care in patients with acute ischemic stroke with a small infarct core, a proximal intracranial arterial occlusion, and moderate-to-good collateral circulation.

Methods: We randomly assigned participants to receive standard care (control group) or standard care plus endovascular treatment with the use of available thrombectomy devices (intervention group).

Mechanical thrombectomy with the Solitaire stent: is there a learning curve in achieving rapid recanalization times?

Methods: In acute ischemic stroke, good outcome following successful recanalization is time dependent. In patients undergoing endovascular therapy at our institution, recanalization times with the Solitaire stent were retrospectively evaluated to assess for the presence of a learning curve in achieving rapid recanalization.

Methods: We reviewed patients who presented to our stroke center and achieved successful recanalization with the Solitaire stent exclusively.