Information

What can be learned from a persistent typing or writing error that happens frequently?

What can be learned from a persistent typing or writing error that happens frequently?

There is a specific typing or writing error that I make frequently, and would like to know more about.

Often when I'm typing or handwriting, I end one word with the ending of the next one, even when the resulting word does not exist. For example, a personal name that I have had to type a lot lately is "Julio Alves", but most of the time I typed "Julios" instead, which is not a real name.


Questions about typing or writing errors come up on the forum from time to time (see example provided in comments). Posters are usually interested in:

  1. Term for describing the error.
  2. Frequency of occurrence.
  3. Cause and treatment.

Typos are common, and may improve with practice or training, though some conditions associated with more typos (eg, dyslexia, dyspraxia, dysgraphia) may prompt treatment. However, I am not aware of specific typographical errors being linked with specific conditions, except perhaps for spelling errors. As such, there is no value in classifying a particular error type for diagnostic purposes - it won't tell you anything useful about your brain.

There are several different ways to categorize typographical errors, depending on why you want to do so. For example, psycholinguists may find error classifications informative regarding the way our brain processes language; and historians may use error classifications to establish phylogeny of manuscripts. The term for a given error would consequently depend on the classification system used.

Human-computer interaction experts are also interested in error classification systems to help identify and prevent or correct common typing errors automatically. For example, Kano et al (2007) developed a classification system to help track children's progress with their typing skills. The researchers describe a number of previously developed classification systems, as well as the new system they developed, along with the frequency of occurrence of each type of error in studies conducted, so check out the paper for some rough estimates.

As an example, the type of error described in the question may be classified as an omission, fusion, blend, combination of word omission and insertion, space error, contamination, or substitution. In all cases, it appears to be rare relative to other kinds of typing errors.


I do not have much research to support my claims, but yeah it is pretty common, the most simple explanation being that while writing we plan what we have to write at least one line in advance most of the time, so the brain is actually ahead of our hands in thinking of that sentence and actually writing it down… basically, you're thinking something and typing something else - two different positions in the sentence. Now, this sometimes causes some confusion, you can put the ending letter as you said by merging two adjacent words or sometimes even skip a word or two altogether. While reading, it's common to mess up sentences especially as one approaches the end of a printed line. So, no, I don't think that what you're experiencing is something serious but well, some professional opinion won't hurt.


Research

Research-Based and Classroom Tested!

The design of Read, Write & Type is based on the best methods of reading instruction, and years of research in brain development. The program itself has been rigorously tested in elementary classrooms for over 10 years, and has produced significant reading improvement. RWT brings together the fundamental principles of reading instruction, with an emphasis on writing as a route to reading, in a program packed with visually exciting and engaging games and challenges. Prominent researchers, as well as our top teachers, report that the most effective reading instruction combines the best elements of whole language with those of phonics and phonemic awareness. In addition, the process of learning to read involves “breaking the alphabetic code”, that is, mastering the skills of both decoding the letters that make up words when reading, and encoding, putting together letters that make up words when writing. Reading methods that emphasize writing as a route to reading are powerful and revolutionary. And they are changing the way children learn.

Spanish-speaking Primary Students Boost Reading Skills in an After-School Computer Program using Read, Write & Type

In a project funded by the National Institute for Child Health and Human Development, (NICHD), sixteen Spanish-speaking 6-7 year olds attended an after-school class for 60 hours using the Read, Write & Type. Their progress in reading was compared to that of 16 comparable controls who either went home after school, or attended day-care or after-school tutoring. All 32 students were struggling to read and were in the lowest 40% of the class on reading scores. The groups were randomly assigned. Their home language was Spanish, and their Quick English Start (QSE) scores classified them with Limited English Proficiency (LEP). Mean QSE scores for the RWT group were 62 and for the Control Group were 65. At this school, primary students were receiving instruction in English with support in Spanish. All the teachers were bilingual but used primarily English in class except for brief clarification in Spanish. Read, Write & Type (RWT), is a 40-level software adventure that provides instruction in phonemic awareness, phonics, spelling, reading, writing, typing, and word processing. The RWT Learning System provides systematic instruction in all 40 phonemes while children sound-out and spell hundreds of words, phrases, and engaging stories. A second CD monitors progress and takes students to appropriate practice if they are not quite ready to move to the next level. The RWT group received 60-70 hours of instruction and all 16 students finished the 40 levels of the program. Classes with two teachers and one aide ran for one hour every day after school, 5 days/week. They used the new version of Read, Write & Type which can be set to provide Help and Instructions in Spanish. Spanish Help is optional and can be accessed by clicking on a Yellow Balloon. Spanish Instructions are provided anytime new instructions are provided in English. (When students are introduced to a new phoneme, or new concept — for example, when they are told that names start with capital letters, and are shown how to use the shift key to make a capital — all the instructions are in both English and Spanish). Classes started with warm-ups on the floor. Teachers used the Read, Write & Type lesson plans to structure the warm-ups. Students were introduced to a new Storyteller character and the sound that Storyteller represents. They worked on naming pictures that they would encounter in the computer program.. They generated sentences with the picture words. They analyzed the beginning, middle or ending sound of the words. They thought of other words with the same beginning sound. They discussed new vocabulary words. They practiced using the correct fingers on the paper keyboards as they sounded out each phoneme (chanting aloud in unison) in dictated words or short phrases like FAT CAT or RED JET. Then students spent about 30 minutes at the computer progressing through the 40 levels of the Read, Write & Type CD. After every 4 phonemes, they used the Spaceship Challenge CD to play games that assessed their progress in Phonics, Spelling, and Reading Comprehension. If their scores indicated that they were not ready to move to the next level, they clicked on the Bonus Blimp which took them automatically to activities they needed to practice before trying to pass the Spaceship games again. Students were tested before and after RWT with Woodcock-Johnson Word Attack (reading nonsense words) and Word Identification (reading words) in both Spanish (Munoz) and English.

Spanish Spanish English English
Word Word Word Word
Attack ID Attack ID
RWT Group
Before 10.4 21.1 7.18 23.6
After 16.9 27.8 16.7 33.4
Control Group
Before 10.8 20 7 25
After 14.4 24.8 12.6 29.6

Data were analyzed using an analysis of covariance to see if the posttest scores were significantly different when the pretest on that measure was used as the covariate. The RWT group showed significantly greater improvement on the English Word Attack (p < .02) and English Word Identification (p< .01), suggesting that an after-school program using the Read, Write & Type can be very effective at improving reading scores significantly for LEP primary students who are struggling to read. Because students received no direct instruction in Spanish reading skills, a more surprising finding was that the RWT group also improved more on the Spanish Word Attack (p<.01), suggesting that the development of phonemic awareness and phonics skills in English may affect those skills in Spanish as well. Spanish uses the same alphabet and is more phonetically regular than English, although a number of the phonemes, particularly vowel sounds, are different. But learning to segment words into their component phonemes (phonemic awareness) is the same process in both languages and one of the critical steps to reading.

Read, Write & Type Research Results: Florida State University

Dr. Joseph Torgesen, Distinguished Research Professor, and National Reading Expert, conducted a study at Florida State University with a group of first graders. Identified as at-risk for reading failure, they were evaluated over a 2-year period in a program using Read, Write & Type. The children showed large gains in reading skills from pre to post-tests, with very large gains in fluency and accuracy. Reading comprehension scores were also higher than expected based on the children’s general verbal ability. Click here to read Dr. Torgesen’s report.

Dr. Torgesen talks about the results: “We have been using Read, Write & Type to support small group instruction in reading for first grade children who are identified as at risk for reading failure. This project is being conducted with support from the National Institute of Child Health and Human Development. With its emphasis on phonological awareness, letter-sound knowledge and phonetic decoding in reading and spelling, Read, Write & Type is entirely consistent with recent discoveries that underline the importance of these skills to the growth of good reading ability.” “Read, Write & Type is an excellent example of the very best in computer applications to provide support for children learning to read. The program not only incorporates the most important principles of beginning reading instruction, but it has also brought them together in a package that is very engaging for children. The great strength of Read, Write & Type is that it provides explicit and systematic instruction in reading and spelling strategies in the context of meaningful and engaging writing and reading activities.

Read, Write & Type Research Results: The Writing Wagon Project

In a classroom study conducted at Millard School in Fremont, California, 94 first graders received instruction using Read, Write & Type in two 1-hour sessions per week for a seven month period. The performance of these children was compared to that of 50 first graders from a comparable elementary school who started with higher reading levels than the students from Millard School. The Millard School children achieved significantly higher end of year scores on phoneme blending, reading nonwords, and spelling. The Writing Wagon Project, carried out by Talking Fingers™ (CNS) and funded by the John S. and James L. Knight Foundation, delivered laptop computers for 56 hours (2 hours/week, November, 1996-June, 1997) to 94 first graders at Millard School in Fremont, California. Click here to see chart of results The 94 Millard first graders and a comparison group of 50 first graders at a nearby school were tested at the beginning and at the end of the project with the following tests: 1. Blending Phonemes, 2. Reading Nonwords, 3. Reading Words, 4. Elision, 5. Spelling. They were also tested at the end of the project with the following tests: 6. Woodcock-Johnson Word Attack, 7. Woodcock-Johnson Word Identification, 8. WRAT Spelling, 9. Typing. In summary, although the Comparison Group started out ahead on every test, the RWT Group scored significantly higher on Blending Phonemes, Reading Nonwords, and Spelling at the end of the project and made significantly greater improvement on all pre-post tests than the Comparison Group. They could find keys (keyboard and screen covered) with an average of 93% accuracy. Students in a small Special Day class (including several autistic students) also used the computers twice/week. Although they were not tested, the teacher reports that students made noticeable progress in reading, writing, and typing. These students were highly motivated to use the computer and were more focused while working at the computer with headphones than they were during teacher instruction. Conclusions: The Read, Write & Type approach boosted first grade reading and spelling scores significantly. In addition, students acquired a foundation of computer skills that will make their work more and more efficient as they continue through elementary school. This research suggests that if this approach were implemented widely, it could make a significant improvement in reading scores across the nation.

Read, Write & Type Research Results: Family Literacy Project

The Family Literacy Project, funded by the Knight Foundation, informally explored the effectiveness of Read, Write & Type with children and adults learning English as a second language. First and second graders used their new Read, Write & Type skills to help an adult family member learn English. A group of Vietnamese families and a group of Hispanic families participated for two nights a week in four 6-week sessions. This project was not designed to collect formal data, but both the adults and children found it very enjoyable. There were waiting lists for each session.

Los Altos School District # 1 in Reading After Using Read, Write & Type

Talking Fingers (CNS) carried out an extensive research and development program from 1990 to 1993 with the Read, Write & Type prototype (called Talking Fingers) at Downer Elementary School in Richmond, California, and Springer Elementary School, in Los Altos, California. As a result, in 1993 Talking Fingers (CNS) collaborated with the Los Altos School District, in Los Altos, California, on a $550,000 project to set up Talking Fingers writing labs in all six elementary schools in the district and to evaluate their effectiveness. The Los Altos District has since upgraded to labs using Read, Write & Type, and in 1999 took first place in all of California in 4th grade reading achievement. In an article in Education Week (March 31, 1999), Jane Croom, a parent of two children from the original project, related a personal story: her 7th grade son, who began using the program in first grade, now writes extensively and types 100 words per minute. Click here to learn more about Talking Fingers, Inc.


G. GEOLOCATION DATA

1. I automatically collect geolocation information from users of my children’s app, but I do not use this information for anything. Am I responsible for notifying parents and getting their consent to such collection?

Yes. COPPA covers the collection of geolocation information, not just its use or disclosure.

2. What if I give my users a choice to turn off geolocation information? Do I still have to notify parents and get prior parental consent?

COPPA is designed to notify parents and give them the choice to consent. Therefore, it is not sufficient to provide such notification and choice to the child user of a website or service. If the operator intends to collect geolocation information, the operator will be responsible for notifying parents and obtaining their consent prior to such collection.

3. The Rule covers “geolocation information sufficient to identify street name and name of city or town.” What if my children’s app only collects coarse geolocation information, tantamount to collecting a ZIP code but nothing more specific?

COPPA does not require an operator to notify parents and obtain their consent before collecting the type of coarse geolocation services described. However, the operator should be quite certain that, in all instances, the geolocation information it collects is more general than that sufficient to identify street name and name of city or town.

4. The geolocation information I collect through my app provides coordinate numbers. It does not specifically identify a street name and name of city or town. Do I have to notify parents and get their consent in this instance? What if I collect other types of information, such as wireless network information, that can be used to determine precise location?

COPPA covers the collection of geolocation information “sufficient” to identify street name and name of city or town. COPPA applies even if the child is not asked to provide an actual street address. For example, COPPA would apply if an app collects the user’s longitude and latitude. Similarly, the Commission alleged that COPPA applied in United States v. InMobi Pte Ltd., where the company collected wireless network identifiers to infer the child’s precise location without providing notice or obtaining verifiable parental consent.


Acknowledging, Paraphrasing, and Quoting Sources

When you write at the college level, you often need to integrate material from published sources into your own writing. This means you need to be careful not to plagiarize: “to use and pass off (the ideas or writings of another) as one’s own” (American Heritage Dictionary) or, in the words of the University of Wisconsin’s Academic Misconduct guide, to present “the words or ideas of others without giving credit” (“Plagiarism,” ¶ 1). The University takes plagiarism seriously, and the penalties can be severe.

This handout is intended to help you use source materials responsibly and avoid plagiarizing by (a) describing the kinds of material you must document (b) illustrating unsuccessful and successful paraphrases (c) offering advice on how to paraphrase and (d) providing guidelines for using direct quotations.

What You Must Document

If you use an author’s specific word or words, you must place those words within quotation marks and you must credit the source.

Information
and Ideas

Even if you use your own words, if you obtained the information or ideas you are presenting from a source, you must document the source.

Information: If a piece of information isn’t common knowledge (see #3 below), you need to provide a source.

Ideas: An author’s ideas may include not only points made and conclusions drawn, but, for instance, a specific method or theory, the arrangement of material, or a list of steps in a process or characteristics of a medical condition. If a source provided any of these, you need to acknowledge the source.

Common Knowledge

You do not need to cite a source for material considered common knowledge.

General common knowledge is factual information considered to be in the public domain, such as birth and death dates of well-known figures, and generally accepted dates of military, political, literary, and other historical events. In general, factual information contained in multiple standard reference works can usually be considered to be in the public domain.

Field-specific common knowledge is “common” only within a particular field or specialty. It may include facts, theories, or methods that are familiar to readers within that discipline. For instance, you may not need to cite a reference to Piaget’s developmental stages in a paper for an education class or give a source for your description of a commonly used method in a biology report–but you must be sure that this information is so widely known within that field that it will be shared by your readers.

If in doubt, be cautious and cite the source. And in the case of both general and field-specific common knowledge, if you use the exact words of the reference source, you must use quotation marks and credit the source.

The way that you credit your source depends on the documentation system you’re using. If you’re not sure which documentation system to use, ask the course instructor who assigned your paper. You can pick up a Writing Center handout or check our Web site (www.wisc.edu/writing) for the basics of several commonly used styles (American Political Science Association, APSA American Psychological Association, APA Chicago/Turabian Council of Biology Editors, CBE Modern Language Association, MLA and Numbered References).

Sample Paraphrases—Unsuccessful and Successful

Paraphrasing is often defined as putting a passage from an author into “your own words.” But what are your own words? How different must your paraphrase be from the original? The paragraphs below provide an example by showing a passage as it appears in the source (A), two paraphrases that follow the source too closely (B and C), and a legitimate paraphrase (D). The student’s intention was to incorporate the material in the original passage A into a section of a paper on the concept of “experts” that compared the functions of experts and nonexperts in several professions.

A. The Passage as It Appears in the Source (indented to indicate a lengthy direct quotation)

Critical care nurses function in a hierarchy of roles. In this open heart surgery unit, the nurse manager hires and fires the nursing personnel. The nurse manager does not directly care for patients but follows the progress of unusual or long-term patients. On each shift a nurse assumes the role of resource nurse. This person oversees the hour-by-hour functioning of the unit as a whole, such as considering expected admissions and discharges of patients, ascertaining that beds are available for patients in the operating room, and covering sick calls. Resource nurses also take a patient assignment. They are the most experienced of all the staff nurses. The nurse clinician has a separate job description and provides for quality of care by orienting new staff, developing unit policies, and providing direct support where needed, such as assisting in emergency situations. The clinical nurse specialist in this unit is mostly involved with formal teaching in orienting new staff. The nurse manager, nurse clinician, and clinical nurse specialist are the designated experts. They do not take patient assignments. The resource nurse is seen as both a caregiver and a resource to other caregivers. . . . Staff nurses have a hierarchy of seniority. . . . Staff nurses are assigned to patients to provide all their nursing care. (Chase, 1995, p. 156)

Critical care nurses have a hierarchy of roles. The nurse manager hires and fires nurses. S/he does not directly care for patients but does follow unusual or long-term cases. On each shift a resource nurse attends to the functioning of the unit as a whole, such as making sure beds are available in the operating room, and also has a patient assignment. The nurse clinician orients new staff, develops policies, and provides support where needed. The clinical nurse specialist also orients new staff, mostly by formal teaching. The nurse manager, nurse clinician, and clinical nurse specialist, as the designated experts, do not take patient assignments. The resource nurse is not only a caregiver but a resource to the other caregivers. Within the staff nurses there is also a hierarchy of seniority. Their job is to give assigned patients all their nursing care.

Notice that the writer has not only “borrowed” Chase’s material (the results of her research) with no acknowledgment, but has also largely maintained the author’s method of expression and sentence structure. The underlined phrases are directly copied from the source or changed only slightly in form. Even if the student-writer had acknowledged Chase as the source of the content, the language of the passage would be considered plagiarized because no quotation marks indicate the phrases that come directly from Chase. And if quotation marks did appear around all these phrases, this paragraph would be so cluttered that it would be unreadable.

Chase (1995) described how nurses in a critical care unit function in a hierarchy that places designated experts at the top and the least senior staff nurses at the bottom. The experts–the nurse manager, nurse clinician, and clinical nurse specialist–are not involved directly in patient care. The staff nurses, in contrast, are assigned to patients and provide all their nursing care. Within the staff nurses is a hierarchy of seniority in which the most senior can become resource nurses: they are assigned a patient but also serve as a resource to other caregivers. The experts have administrative and teaching tasks such as selecting and orienting new staff, developing unit policies, and giving hands-on support where needed.

This paraphrase is a patchwork composed of pieces in the original author’s language (underlined) and pieces in the student-writer’s words, all rearranged into a new pattern, but with none of the borrowed pieces in quotation marks. Thus, even though the writer acknowledges the source of the material, the underlined phrases are falsely presented as the student’s own.

D. A Legitimate Paraphrase

In her study of the roles of nurses in a critical care unit, Chase (1995) also found a hierarchy that distinguished the roles of experts and others. Just as the educational experts described above do not directly teach students, the experts in this unit do not directly attend to patients. That is the role of the staff nurses, who, like teachers, have their own “hierarchy of seniority” (p. 156). The roles of the experts include employing unit nurses and overseeing the care of special patients (nurse manager), teaching and otherwise integrating new personnel into the unit (clinical nurse specialist and nurse clinician), and policy-making (nurse clinician). In an intermediate position in the hierarchy is the resource nurse, a staff nurse with more experience than the others, who assumes direct care of patients as the other staff nurses do, but also takes on tasks to ensure the smooth operation of the entire facility.

The writer has documented Chase’s material and specific language (by direct reference to the author and by quotation marks around language taken directly from the source). Notice too that the writer has modified Chase’s language and structure and has added material to fit the new context and purpose—to present the distinctive functions of experts and nonexperts in several professions.

Perhaps you’ve noticed that a number of phrases from the original passage appear in the legitimate paraphrase in D above: critical care, staff nurses, nurse manager, clinical nurse specialist, nurse clinician, resource nurse. If all these were underlined, the paraphrase would look much like the “patchwork” in example C. The difference is that the phrases in D are all precise, economical, and conventional designations that are part of the shared language within the nursing discipline (in B and C, they’re underlined only when used within a longer borrowed phrase). In every discipline and in certain genres (such as the empirical research report), some phrases are so specialized or conventional that you can’t paraphrase them except by wordy and awkward circumlocutions that would be less familiar (and thus less readable) to the audience. When you repeat such phrases, you’re not stealing the unique phrasing of an individual writer, but using a common vocabulary shared by a community of scholars.

Some Examples of Shared Language You Don’t Need to Put in Quotation Marks

Conventional designations: e.g., physician’s assistant, chronic low-back pain

Preferred bias-free language: e.g., persons with disabilities

Technical terms and phrases of a discipline or genre: e.g., reduplication, cognitive domain, material culture, sexual harassment

How to Paraphrase

  1. When reading a passage, try first to understand it as a whole, rather than pausing to write down specific ideas or phrases.
  2. Be selective. Unless your assignment is to do a formal or “literal” paraphrase,* you usually don’t need to paraphrase an entire passage instead, choose and summarize the material that helps you make a point in your paper.
  3. Think of what “your own words” would be if you were telling someone who’s unfamiliar with your subject (your mother, your brother, a friend) what the original source said.
  4. Remember that you can use direct quotations of phrases from the original within your paraphrase and that you don’t need to change or put quotation marks around shared language (see box above).

*See Spatt (1999), pp. 99-103 paraphrase is used in this handout in the more common sense of a summary-paraphrase or what Spatt calls a “free paraphrase” (p. 103).

  1. Look away from the source then write.
    Read the text you want to paraphrase several times—until you feel that you understand it and can use your own words to restate it to someone else. Then, look away from the original and rewrite the text in your own words.
  2. Take notes.

Take abbreviated notes set the notes aside then paraphrase from the notes a day or so later, or when you draft.

If you find that you can’t do 1 or 2, this may mean that you don’t understand the passage completely or that you need to use a more structured process until you have more experience in paraphrasing. The method below is not only a way to create a paraphrase but also a way to understand a difficult text.

For example, consider the following passage from Love and Toil (a book on motherhood in London from 1870 to 1918), in which the author, Ellen Ross, puts forth one of her major arguments:

Love and Toil maintains that family survival was the mother’s main charge among the large majority of London’s population who were poor or working class the emotional and intellectual nurture of her child or children and even their actual comfort were forced into the background. To mother was to work for and organize household subsistence. (p. 9)

Begin by starting at a different place in the passage and/or sentence(s), basing your choice on the focus of your paper. This will lead naturally to some changes in wording. Some places you might start in the passage above are “The mother’s main charge,” “Among the . . . poor or working class,” “Working for and organizing household subsistence,” or “The emotional and intellectual nurture.” Or you could begin with one of the people the passage is about: “Mothers,” “A mother,” “Children,” “A child.” Focusing on specific people rather than abstractions will make your paraphrase more readable.

At this stage, you might also break up long sentences, combine short ones, expand phrases for clarity, or shorten them for conciseness, or you might do this in an additional step. In this process, you’ll naturally eliminate some words and change others.

Here’s one of the many ways you might get started with a paraphrase of the passage above by changing its structure. In this case, the focus of the paper is the effect of economic status on children at the turn of the century, so the writer begins with children:

Children of the poor at the turn of the century received little if any emotional or intellectual nurturing from their mothers, whose main charge was family survival. Working for and organizing household subsistence were what defined mothering. Next to this, even the children’s basic comfort was forced into the background (Ross, 1995).

Now you’ve succeeded in changing the structure, but the passage still contains many direct quotations, so you need to go on to the second step.

Use synonyms or a phrase that expresses the same meaning.

Leave shared language (box, p. 3) unchanged.

It’s important to start by changing the structure, not the words, but you might find that as you change the words, you see ways to change the structure further. The final paraphrase might look like this:

According to Ross (1993), poor children at the turn of the century received little mothering in our sense of the term. Mothering was defined by economic status, and among the poor, a mother’s foremost responsibility was not to stimulate her children’s minds or foster their emotional growth but to provide food and shelter to meet the basic requirements for physical survival. Given the magnitude of this task, children were deprived of even the “actual comfort” (p. 9) we expect mothers to provide today.

You may need to go through this process several times to create a satisfactory paraphrase.

Using Direct Quotations

Use direct quotations only if you have a good reason. Most of your paper should be in your own words.

· To show that an authority supports your point

· To present a position or argument to critique or comment on

· To include especially moving or historically significant language

· To present a particularly well-stated passage

· whose meaning would be lost or changed if paraphrased or summarized

One of your jobs as a writer is to guide your reader through your text. Don’t simply drop quotations into your paper and leave it to the reader to make connections. Integrating a quotation into your text usually involves two elements:

  • A signal that a quotation is coming—generally the author’s name and/or a reference to the work
  • An assertion that indicates the relationship of the quotation to your text

Often both the signal and the assertion appear in a single introductory statement, as in the example below. Notice how a transitional phrase also serves to connect the quotation smoothly to the introductory statement.

Ross (1993), in her study of poor and working-class mothers in London from 1870-1918 [signal], makes it clear that economic status to a large extent determined the meaning of motherhood [assertion]. Among this population [connection], “To mother was to work for and organize household subsistence” (p. 9).

The signal can also come after the assertion, again with a connecting word or phrase:

Illness was rarely a routine matter in the nineteenth century [assertion]. As [connection] Ross observes [signal], “Maternal thinking about children’s health revolved around the possibility of a child’s maiming or death” (p. 166).

Incorporate short direct prose quotations into the text of your paper and enclose them in double quotation marks, as in the examples above. Begin longer quotations (for instance, in the APA system, 40 words or more) on a new line and indent the entire quotation (i.e., put in block form), with no quotation marks at beginning or end, as in the quoted passage from Chase on p. 2, A. Rules about the minimum length of block quotations, how many spaces to indent, and whether to single- or double-space extended quotations vary with different documentation systems check the guidelines for the system you’re using.

Punctuation with Quotation Marks

1. Parenthetical citations. With short quotations, place citations outside of closing quotation marks, followed by sentence punctuation (period, question mark, comma, semi-colon, colon):

Menand (2002) characterizes language as “a social weapon” (p. 115).

With block quotations, check the guidelines for the documentation system you are using. For APA, used in this handout, see sample A on p. 2, and sample C (the quotation from Ross) on p. 4.

2. Commas and periods. Place inside closing quotation marks when no parenthetical citation follows:

Hertzberg (2002) notes that “treating the Constitution as imperfect is not new,” but because of Dahl’s credentials, his “apostasy merits attention” (p. 85).

3. Semi-colons and colons. Place outside of closing quotation marks (or after a parenthetical citation).

4. Question marks and exclamation points.

Place inside closing quotation marks if the quotation is a question/exclamation:

Menand (2001) acknowledges that H. W. Fowler’s Modern English Usage is “a classic of the language,” but he asks, “Is it a dead classic?” (p. 114). [Note that a period still follows the closing parenthesis.]

Place outside of closing quotation marks if the entire sentence containing the quotation is a question or exclamation:

How many students actually read the guide to find out what is meant by “academic misconduct”?

5. Quotations within quotations. Use single quotation marks for the embedded quotation:

According to Hertzberg (2002), Dahl gives the U. S. Constitution “bad marks in ‘democratic fairness’ and ‘encouraging consensus’” (p. 90). [The phrases “democratic fairness” and “encouraging consensus” are already in quotation marks in Dahl’s sentence.]

Indicating Changes in Quotations

Use ellipsis points (. . .) to indicate an omission within a quotation–but not at the beginning or end unless it’s not obvious that you’re quoting only a portion of the whole.

Within quotations, use square brackets [ ] (not parentheses) to add your own clarification, comment, or correction. Use [sic] (meaning “so” or “thus”) to indicate that a mistake is in the source you’re quoting and is not your own.

Some Useful Sources on Paraphrasing and Summarizing

American heritage dictionary of the English language (4th ed.). (2000). Retrieved January 7, 2002, from www.bartleby.com/61/.

Bazerman, C. (1995). The informed writer: Using sources in the disciplines (5th ed). Boston: Houghton Mifflin.

Leki, I. (1995). Academic writing: Exploring processes and strategies (2nd ed.) New York: St. Martin’s Press, pp. 185-211.

Spatt, B. (1999). Writing from sources (5th ed.) New York: St. Martin’s Press, pp. 98-119 364-371.

Chase, S. K. (1995). The social context of critical care clinical judgment. Heart and Lung, 24, 154-162.

Hertzberg, H. (2002, July 29). Framed up: What the Constitution gets wrong [Review of R. A. Dahl, How democratic is the Constitution?]. New Yorker, pp. 85-90.

Menand, L. (2002, November 26). Slips of the tongue [Review of J. McMorris, The warden of English: The life of H. W. Fowler]. New Yorker, pp. 112-116.

Ross, E. (1993). Love and toil: Motherhood in outcast London, 1870-1918. New York: Oxford University Press.

Spatt, B. (1999). Writing from sources (5th ed.). New York: St. Martin’s Press.


6. TRACERT: Trace Route

TRACERT is a fascinating Windows Command to use. If you’re ever curious to see the path your internet traffic takes to get from your browser to a remote system like Google servers, you can use TRACERT to see it.

The command stands for “Trace Route”, which sends packets out to a remote destination (server or website), and provides you with all of the following information:

  • Number of hops (intermediate servers) before getting to the destination
  • Time it takes to get to each hop
  • The IP and sometimes the name of each hop

TRACERT can reveal how the routes of your internet requests change depending where you’re accessing the web. It also helps with troubleshooting a router or switch on a local network that may be problematic.


Why You Should Stop Being So Hard on Yourself

Self-criticism can take a toll on our minds and bodies. It’s time to ease up.

“We’re all our own worst critics.” Ever heard that one before?

Yes, it’s an obnoxious cliché, but it’s not just self-help fluff. Evolutionary psychologists have studied our natural “negativity bias,” which is that instinct in us all that makes negative experiences seem more significant than they really are.

In other words: We’ve evolved to give more weight to our flaws, mistakes and shortcomings than our successes.

“Self-criticism can take a toll on our minds and bodies,” said Dr. Richard Davidson, founder and director of the Center for Healthy Minds at the University of Wisconsin-Madison, where he also teaches psychology and psychiatry.

“It can lead to ruminative thoughts that interfere with our productivity, and it can impact our bodies by stimulating inflammatory mechanisms that lead to chronic illness and accelerate aging,” he said.

But that’s not the end of the story. There are ways around our negativity bias, and it is possible to turn self-criticism into opportunities for learning and personal growth. (Really!) But first, let’s talk about how we got here.


Moving the Focus From Errors to Safety

Errors occur in health care as well as every other very complex system that involves human beings. The message in To Err is Human was that preventing death and injury from medical errors requires dramatic, systemwide changes. 1 Among three important strategies—preventing, recognizing, and mitigating harm from error—the first strategy (recognizing and implementing actions to prevent error) has the greatest potential effect, just as in preventive public health efforts.

The IOM committee recognized that simply calling on individuals to improve safety would be as misguided as blaming individuals for specific errors. Health care professionals have customarily viewed errors as a sign of an individual’s incompetence or recklessness. As a result, rather than learning from such events and using information to improve safety and prevent new events, health care professionals have had difficulty admitting or even discussing adverse events or “near misses,” often because they fear professional censure, administrative blame, lawsuits, or personal feelings of shame. Acknowledging this, the report put forth a four-part plan that applies to all who are, or will be, at the front lines of patient care clinical administrators regulating, accrediting, and licensing groups boards of directors industry and government agencies. It also suggested actions that patients and their families could take to improve safety.

The committee understood that need to develop a new field of health care research, a new taxonomy of error, and new tools for addressing problems. It also understood that responsibility for taking action could not be borne by any single group or individual and had to be addressed by health care organizations and groups that influence regulation, payment, legal liability, education and training, as well as patients and their families. The report called on Congress to create a National Center for Patient Safety within the Agency for Healthcare Research and Quality, to develop new tools and patient care systems that make it easier to do things right and harder to do things wrong. This handbook is a direct result of the implementation of those recommendations.

Improving Safety by Understanding Error

Every day, physicians, advance practice nurses, nurses, pharmacists, and other hospital personnel recognize and correct errors and usually prevent harm. Errors, defined as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim,” 1 do not all result in injury or harm. Errors that do cause injury or harm are sometimes called preventable adverse events—that is, the injury is thought to be due to a medical intervention, not the underlying condition of the patient. Errors that result in serious injury or death, considered “sentinel events” by the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations [JCAHO]), 5 signal the need for an immediate response, analysis to identify all factors contributing to the error, and reporting to the appropriate individuals and organizations 7 to guide system improvements.

The key question for the IOM, as for many health professionals now, was what could be done to improve safety. To differentiate between individual factors and system factors, the report distinguished between the “sharp” end of a process in which the event occurs (e.g., administration of the wrong dose of medication that is fatal, a mishap during surgery) and the 𠇋lunt” end in which many factors (called latent conditions), which may have seemed minor, have interacted and led to an error. 6 These latent conditions may be attributable to equipment design or maintenance, working conditions, design of processes so that too many handoffs occur, failures of communication, and so forth. 7𠄹

Leape 8 greatly enhanced our understanding of errors by distinguishing between two types of cognitive tasks that may result in errors in medicine. The first type of task occurs when people engage in well-known, oft-repeated processes, such as driving to work or making a pot of coffee. Errors may occur while performing these tasks because of interruptions, fatigue, time pressure, anger, distraction, anxiety, fear, or boredom. By contrast, tasks that require problem solving are done more slowly and sequentially, are perceived as more difficult, and require conscious attention. Examples include making a differential diagnosis and readying several types of surgical equipment made by different manufacturers. Errors here are due to misinterpretation of the problem that must be solved and lack of knowledge. Keeping in mind these two different kinds of tasks is helpful to understanding the multiple reasons for errors and is the first step in preventing them.

People make errors for a variety of reasons that have little to do with lack of good intention or knowledge. Humans have many intellectual strengths (e.g., large memory capacity and an ability to react creatively and effectively to the unexpected) and limitations (e.g., difficulty attending carefully to several things at once and generally poor computational ability, especially when tired). 12 Improving safety requires respecting human abilities by designing processes that recognize human strengths and weaknesses.

There are many opportunities for individuals to prevent error. Some actions are clinically oriented and evidence-based: communicating clearly to other team members, even when hierarchies and authority gradients seem to discourage it requesting and giving feedback for all verbal orders and being alert to �idents waiting to happen.” Other opportunities are broader in focus or address the work environment and may require clinical leadership and changing the workplace culture: simplifying processes to reduce handoffs and standardizing protocols developing and participating in multidisciplinary team training involving patients in their care and being receptive to discussions about errors and near misses by paying respectful attention when any member of the staff challenges the safety of a plan or a process of care.

However, large, complex problems require thoughtful, multifaceted responses by individuals, teams, and organizations. That is, preventing errors and improving safety require a systems approach to the design of processes, tasks, training, and conditions of work in order to modify the conditions that contribute to errors. Fortunately, there is no need to start from scratch. The IOM report included some guidance based on what was known at the time, and other specific evidence has accumulated since then that can be put in practice today. Designing for safety requires a commitment to safety, a thorough knowledge of the technical processes of care, an understanding of likely sources of error, and effective ways to reduce errors.

A Report From the Trenches—Systems, not Shame

These types of questions are by no means unusual. Partly because of its sheer complexity and the number of different individuals with different training and approaches, health care is prone to harm from errors𠅎specially in operating rooms, intensive care units (ICUs), and emergency departments where there is little time to react to unexpected events𠅊nd consequences can be very serious. Although most early studies focused on the hospital setting, medical errors present a problem in all settings, including outpatient surgical centers, physician offices and clinics, nursing homes, and the home, especially when patients and families are asked to use increasingly complicated equipment.

Patients should not be harmed by the health care system that is supposed to help them, but the solution does not lie in assigning blame or urging health professionals to be more careful. In what seems to be a simple example, an ICU nurse was wheeling a patient on a gurney to radiology when his knee struck a fire extinguisher hanging on the wall, resulting in the patient needing extra care. In response, the nurse may have been scolded by her supervisor and told to be more careful, or punished in some other way everyone would feel the problem had been solved. Yet, would that make the hospital safer? Would it prevent other events that are similar but slightly different in circumstances from happening with other staff and patients in other units? The answer is an emphatic no.

Improving safety, arises from attention to the often multiple latent factors that contribute to errors and in some cases, to injury. In the above example, such factors included: 1) the nurse having to move the patient herself because transport had never arrived 2) a change in hospital policy, so that only one instead of two people guide gurneys 3) the failure to mount the fire extinguisher in a recessed niche 4) the decision to transport a seriously ill patient rather than having mobile equipment come to him, requiring extra “handoffs” and opportunities for injury and 5) poor gurney design, making steering difficult, and possibly still other factors.

The IOM’s Four-Part Message

The IOM committee sought what could be learned from other disciplines and applied in health care by clinical and administrative leadership. It described actions that health care professionals can take now in their own institutions, whether they are new trainees, experienced clinical leaders, or instructors. The major thrust of the report was a four-part plan, intended to create financial and regulatory incentives to create a safer health care system and a systematic way to integrate safety into the process of care (the focus of this chapter). The four parts of the IOM recommendations are described below:

The committee recognized that some actions could be taken at the national level as described in the recommendations contained in Parts 1𠄳. Yet if patient safety were really to improve, the committee knew it would take far more than reporting requirements and regulations. Creating and sustaining a culture of safety (Part 4) is needed, which would require continuing local action by thousands of health care organizations and the individuals working in these settings at all levels of authority. Hospital leadership must provide resources and time to improve safety and foster an organizational culture that encourages recognition and learning from errors. A culture of safety cannot develop without trust, keen observation, and extensive knowledge of care processes at all levels, from those on the front lines of health care to those in leadership and management positions.


Anthropomorphism

Sometimes you cannot easily find the right wording in order to explain a cause and effect relationship, or you may not understand the concept well enough in order to write an explanation. Anthropomorphism is a type of oversimplification that helps the writer avoid a real explanation of a mechanism. A couple of examples should make the point for you.

The thought behind the statement is correct, but the statement does not represent the correct mechanism. Sodium has no free will. It tends to move toward the compartment with lower concentration because the probability of a sodium ion moving through a channel on the more concentrated side of the membrane exceeds the probability that an ion will move through a channel on the less concentrated side. If you don't want to explain the principle behind osmosis, you can simply state that osmotic pressure tends to drive sodium from the more highly to less highly concentrated side of a membrane.


Causes

We don't yet know exactly what causes cognitive dysfunction in these conditions, but we have a lot of theories about possible contributing factors, including:

  • Sleep that isn't restful or restorative
  • Mental distraction due to pain
  • Overexertion in ME/CFS as a consequence of post-exertional malaise
  • Medications used to treat pain
  • Medications used for treating FMS and ME/CFS
  • Abnormal blood flow to some areas of the brain
  • Abnormal connectivity patterns between different regions of the brain
  • Abnormal function of certain brain chemicals (neurotransmitters)
  • Premature aging of the brain

In FMS, fibro fog generally is worse when pain is worse. In both FMS and ME/CFS, it can be exacerbated when you're especially fatigued, anxious, under pressure, or dealing with sensory overload.

Depression, which is common in FMS and ME/CFS, also is associated with cognitive dysfunction. Some studies, however, show that the severity of brain fog in these conditions is not related to symptoms of depression.


Medical Error Reduction and Prevention

Medical errors are a serious public health problem and a leading cause of death in the United States. It is challenging to uncover a consistent cause of errors and, even if found, to provide a consistent viable solution that minimizes the chances of a recurrent event. By recognizing untoward events occur, learning from them, and working toward preventing them, patient safety can be improved.

Part of the solution is to maintain a culture that works toward recognizing safety challenges and implementing viable solutions rather than harboring a culture of blame, shame, and punishment. Healthcare organizations need to establish a culture of safety that focuses on system improvement by viewing medical errors as challenges that must be overcome. All individuals on the healthcare team must play a role in making the provision of healthcare safer for patients and healthcare workers.

All providers know medical errors create a serious public health problem that poses a substantial threat to patient safety. Yet, one of the most challenging unanswered questions is "What constitutes a medical error?" The answer to this basic question has not been clearly established. Due to unclear definitions, “medical errors” are difficult to scientifically measure. A lack of standardized nomenclature and overlapping definitions of medical errors has hindered data analysis, synthesis, and evaluation.

There are two major types of errors:

Errors of omission occur as a result of actions not taken. Examples are not strapping a patient into a wheelchair or not stabilizing a gurney prior to patient transfer.

Errors of the commission occur as a result of the wrong action taken. Examples include administering a medication to which a patient has a known allergy or not labeling a laboratory specimen that is subsequently ascribed to the wrong patient.

Health care professionals experience profound psychological effects such as anger, guilt, inadequacy, depression, and suicide due to real or perceived errors. The threat of impending legal action may compound these feelings. This can also lead to a loss of clinical confidence. Clinicians equate errors with failure, with a breach of public trust, and with harming patients despite their mandate to “first do no harm.”

Fear of punishment makes healthcare professionals reluctant to report errors. While they fear for patients’ safety, they also dread disciplinary action, including the fear of losing their jobs if they report an incident. Unfortunately, failing to report contributes to the likelihood of serious patient harm. Many healthcare institutions have rigid policies in place that also create an adversarial environment. This can cause staff to hesitate to report an error, minimize the problem, or even fail to document the issue. These actions or lack thereof can contribute to an evolving cycle of medical errors. When these errors come to light, they can tarnish the reputation of the healthcare institution and the workers.

Some experts hold that the term “error” is excessively negative, antagonistic and perpetuates a culture of blame. A professional whose confidence and morale has been damaged as a result of an error may work less effectively and may abandon a career in medicine. Many experts suggest the term “error” should not be used at all. Due to the negative connotation, it is prudent to limit the use of the term “error” when documenting in the public medical record. However, adverse patient outcomes may occur because of errors to delete the term obscures the goal of preventing and managing its causes and effects.

Errors, no matter the nomenclature, typically occur from the convergence of multiple contributing factors. Public and legislative intolerance for medical errors typically illustrates a lack of understanding that some errors may not, in fact, be preventable with current technology or the resources available to the practitioner. Human factors are always a problem, and identifying errors permits improvement strategies to be undertaken. In particular, blaming or punishing individuals for errors due to systemic causes does not address the causes nor prevent a repetition of the error. The trend is for patient safety experts to focus on improving the safety of health care systems to reduce the probability of errors and mitigate their effects rather than focus on an individual’s actions. Errors represent an opportunity for constructive changes and improved education in health care delivery.

Governmental, legal, and medical institutions must work collaboratively to remove the culture of blame while retaining accountability. When this challenge is met, health care institutions will not be constrained from measuring targets for process improvement, including all errors, even with adverse outcomes.

Healthcare providers want to improve outcomes while reducing the risk of patient harm. Despite provider best efforts, medical error rates remain high with significant disability and death. Preventable medical errors contribute substantially to healthcare costs, including higher health insurance costs per person expenses. Only by health professionals working together will the cost and injury associated with medical errors be mitigated.

The Joint Commission Patient Safety Goals

The Joint Commission has introduced several patient safety goals to assist institutions and healthcare practitioners in creating a safer practice environment for patients and providers. The Joint Commission Goals include:

Identify patient safety dangers and risks

Identify patients correctly by confirming the identity in at least two ways

Improve communication such as getting test results to the correct person quickly

Prevent infection by hand-cleaning, post-op infection antibiotics, catheter changes, and central line precautions.

Prevent mistakes in surgery by making sure the correct surgery is done on the correct body part pause before surgery to double-check.

Use device alarms and make sure that alarms on medical equipment are heard and checked quickly.

Use medications correctly and safely, double-checking labeling and correctly passing on patient medicines to the next provider.

Label all medications, even those in a syringe. This should preferably be done in the area where the medications are prepared.

Take extra time with patients who have been prescribed anticoagulants and chemotherapeutic agents.

To prevent nosocomial infections, hand washing should be routine before and after visiting each patient.

While it is true that individual providers should be held accountable for their decisions, there is a growing realization that the majority of errors are out of the clinician's control. This being said, it remains difficult to change a culture of non-reporting.

Questions to consider include:

The potential for errors in healthcare is very high. Due to cost control measures, are individuals accountable, or are increased workload and staff fatigue the reason for errors?

Why report? Failure to report errors may subject clinicians to disciplinary action and increased risk for legal liability. Beneficence and nonmaleficence are ethical concepts that are violated when an error is not reported.

Practitioners often fear they will gain a reputation for committing mistakes and may not self-report. They know that mistakes and written warnings are often recorded in personnel files. Does the system need modification to decrease the penalty and encourage reporting?

Punishment may, in fact, reduce reporting errors because of the discipline and humiliation that is associated with repeated errors. Nevertheless, not addressing the problem increases the potential for more adverse events which places more patients at risk. Rather than placing blame, administrators and review boards need to move toward eliminating the blame-shame-discipline structure and move toward a prevention and education structure.

This culture incorporates both learning and improvement efforts that target system redesign and a reporting culture whereby all providers feel safe from retribution and, therefore, report issues about safety that help to constantly improve patient care and improve the safety of the system.

Patient safety has typically been outcome-dependent and the focus has been on preventing patients from experiencing adverse outcomes when receiving medical care. This may stem from Hippocrates, primum no nocere, or “First, do no harm.” While definitions in the literature are unclear, some general concepts can be garnered. Multiple similar definitions are available for each of these terms from various sources the health practitioner should be aware of the general principles and probable meaning.

Active errors are those taking place between a person and an aspect of a larger system at the point of contact.

Active errors are made by people on the front line such as clinicians and nurses. For example, operating on the wrong eye or amputating the wrong leg are classic examples of an active error.

An adverse event is a type of injury that most frequently is due to an error in medical or surgical treatment rather than the underlying medical condition of the patient. Adverse events may be preventable when there is a failure to follow accepted practice at a system or individual level.

Not all adverse outcomes are the result of an error hence, only preventable adverse events are attributed to medical error.

Adverse events can include unintended injury, prolonged hospitalization, or physical disability that results from medical or surgical patient management.

Adverse events can also include complications resulting from prolonged hospitalization or by factors inherent in the healthcare system.

These are errors in system or process design, faulty installation or maintenance of equipment, or ineffective organizational structure.

These are present but may go unnoticed for a long time with no ill effect.

When a latent error occurs in combination with an active human error, some type of event manifests in the patient. The active human error triggers the hidden latent error, resulting in an adverse event.

Latent errors are basically "accidents waiting to happen." A classic example is a hospital with several types of chest drainage sets, all requiring different connections and setups, yet not all frontline clinicians and nurses are familiar with the intricacies of each setup, creating the scenario for potential error.

The failure to complete the intended plan of action or implementing the wrong plan to achieve an aim.

An unintended act or one that fails to achieve the intended outcome.

Deviations from the process of care, which may or may not result in harm.

When planning or executing a procedure, the act of omission or commission that contributes or may contribute to an unintended consequence.

Failure to meet the reasonably expected standard of care of an average, qualified healthcare worker looking after a patient in question within similar circumstances. For example, the healthcare worker may not check up on the pathology report which led to a missed cancer or the surgeon may have injured a nerve by mistaking it for an artery.

Negligent Adverse Events

A subcategory of preventable, adverse events that satisfy the legal criteria used in determining negligence.

The injury caused by substandard medical management.

Any event that could have had an adverse patient consequence but did not.

Potential adverse events that could have caused harm but did not, either by chance or because someone or something intervened.

Near misses provide opportunities for developing preventive strategies and actions and should receive the same level of scrutiny as adverse events.

Never events are errors that should not ever have happened. A classic example of a never event is the development of pressure ulcers or wrong-site surgery. The National Quality Forum has identified the following as Serious Reportable Events:

Noxious Episode

Untoward events, complications, and mishaps that result from acceptable diagnostic or therapeutic measures that are deliberately instituted. For example, sending a hemodynamically unstable trauma patient for prolonged imaging studies instead of the operating room. The result could be a traumatic arrest and death.

The process of amelioration, avoidance, and prevention of adverse injuries or outcomes that arise as a result of the healthcare process.

Potentially Compensable Event

An error that could potentially lead to malpractice claims.

An event due to medical management that resulted in disability, and, subsequently, a prolonged hospitalization.

A deficiency or decision that, if corrected or avoided, will eliminate the undesirable consequence.

Common root causes include:

Changes in mental acumen including not seeking advice from peers, misapplying expertise, not formulating a plan, not considering the most obvious diagnosis, or conducting healthcare in an automatic fashion.

Communication issues, having no insight into the hierarchy, having no solid leadership, not knowing whom to report the problem, failing to disclose the issues, or having a disjointed system with no problem-solving ability.

Deficiencies in education, training, orientation, and experience.

Inadequate methods of identifying patients, incomplete assessment on admission, failing to obtain consent, and failing to provide education to patients.

Inadequate policies to guide healthcare workers.

Lack of consistency in procedures.

Inadequate staffing and/or poor supervision.

Technical failures associated with medical equipment.

No one prepared to accept blame or change the system.

The Joint Commission defines a "sentinel event" as “any unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. The phrase 'or the risk thereof' includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.” (The Joint Commission, 2017). Sentinel events are so-called because once discovered, they frequently indicate the need for an immediate investigation, discovery of the cause, and response.

Extent of the Challenge

Approximately 400,000 hospitalized patients experience some type of preventable harm each year .

Depending on the study, medical errors account for over $4 billion per year.

Medical errors cost approximately $20 billion a year.

Medical errors in hospitals and clinics result in approximately 100,000 people dying each year.

Medical errors typically include surgical, diagnostic, medication, devices and equipment, and systems failures, infections, falls, and healthcare technology.

Missed diagnoses or injuries from medication are common in outpatient settings.

Most malpractice claims in hospitals are related to surgical errors, whereas most claims for outpatient care are related to missed or late diagnosis.

Slightly more than half of the paid malpractice claims are related to outpatient care.

To decrease overhead, hospitals often reduce nursing staff staffing of RNs below target levels is associated with increased mortality.


Why You Should Stop Being So Hard on Yourself

Self-criticism can take a toll on our minds and bodies. It’s time to ease up.

“We’re all our own worst critics.” Ever heard that one before?

Yes, it’s an obnoxious cliché, but it’s not just self-help fluff. Evolutionary psychologists have studied our natural “negativity bias,” which is that instinct in us all that makes negative experiences seem more significant than they really are.

In other words: We’ve evolved to give more weight to our flaws, mistakes and shortcomings than our successes.

“Self-criticism can take a toll on our minds and bodies,” said Dr. Richard Davidson, founder and director of the Center for Healthy Minds at the University of Wisconsin-Madison, where he also teaches psychology and psychiatry.

“It can lead to ruminative thoughts that interfere with our productivity, and it can impact our bodies by stimulating inflammatory mechanisms that lead to chronic illness and accelerate aging,” he said.

But that’s not the end of the story. There are ways around our negativity bias, and it is possible to turn self-criticism into opportunities for learning and personal growth. (Really!) But first, let’s talk about how we got here.


Moving the Focus From Errors to Safety

Errors occur in health care as well as every other very complex system that involves human beings. The message in To Err is Human was that preventing death and injury from medical errors requires dramatic, systemwide changes. 1 Among three important strategies—preventing, recognizing, and mitigating harm from error—the first strategy (recognizing and implementing actions to prevent error) has the greatest potential effect, just as in preventive public health efforts.

The IOM committee recognized that simply calling on individuals to improve safety would be as misguided as blaming individuals for specific errors. Health care professionals have customarily viewed errors as a sign of an individual’s incompetence or recklessness. As a result, rather than learning from such events and using information to improve safety and prevent new events, health care professionals have had difficulty admitting or even discussing adverse events or “near misses,” often because they fear professional censure, administrative blame, lawsuits, or personal feelings of shame. Acknowledging this, the report put forth a four-part plan that applies to all who are, or will be, at the front lines of patient care clinical administrators regulating, accrediting, and licensing groups boards of directors industry and government agencies. It also suggested actions that patients and their families could take to improve safety.

The committee understood that need to develop a new field of health care research, a new taxonomy of error, and new tools for addressing problems. It also understood that responsibility for taking action could not be borne by any single group or individual and had to be addressed by health care organizations and groups that influence regulation, payment, legal liability, education and training, as well as patients and their families. The report called on Congress to create a National Center for Patient Safety within the Agency for Healthcare Research and Quality, to develop new tools and patient care systems that make it easier to do things right and harder to do things wrong. This handbook is a direct result of the implementation of those recommendations.

Improving Safety by Understanding Error

Every day, physicians, advance practice nurses, nurses, pharmacists, and other hospital personnel recognize and correct errors and usually prevent harm. Errors, defined as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim,” 1 do not all result in injury or harm. Errors that do cause injury or harm are sometimes called preventable adverse events—that is, the injury is thought to be due to a medical intervention, not the underlying condition of the patient. Errors that result in serious injury or death, considered “sentinel events” by the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations [JCAHO]), 5 signal the need for an immediate response, analysis to identify all factors contributing to the error, and reporting to the appropriate individuals and organizations 7 to guide system improvements.

The key question for the IOM, as for many health professionals now, was what could be done to improve safety. To differentiate between individual factors and system factors, the report distinguished between the “sharp” end of a process in which the event occurs (e.g., administration of the wrong dose of medication that is fatal, a mishap during surgery) and the 𠇋lunt” end in which many factors (called latent conditions), which may have seemed minor, have interacted and led to an error. 6 These latent conditions may be attributable to equipment design or maintenance, working conditions, design of processes so that too many handoffs occur, failures of communication, and so forth. 7𠄹

Leape 8 greatly enhanced our understanding of errors by distinguishing between two types of cognitive tasks that may result in errors in medicine. The first type of task occurs when people engage in well-known, oft-repeated processes, such as driving to work or making a pot of coffee. Errors may occur while performing these tasks because of interruptions, fatigue, time pressure, anger, distraction, anxiety, fear, or boredom. By contrast, tasks that require problem solving are done more slowly and sequentially, are perceived as more difficult, and require conscious attention. Examples include making a differential diagnosis and readying several types of surgical equipment made by different manufacturers. Errors here are due to misinterpretation of the problem that must be solved and lack of knowledge. Keeping in mind these two different kinds of tasks is helpful to understanding the multiple reasons for errors and is the first step in preventing them.

People make errors for a variety of reasons that have little to do with lack of good intention or knowledge. Humans have many intellectual strengths (e.g., large memory capacity and an ability to react creatively and effectively to the unexpected) and limitations (e.g., difficulty attending carefully to several things at once and generally poor computational ability, especially when tired). 12 Improving safety requires respecting human abilities by designing processes that recognize human strengths and weaknesses.

There are many opportunities for individuals to prevent error. Some actions are clinically oriented and evidence-based: communicating clearly to other team members, even when hierarchies and authority gradients seem to discourage it requesting and giving feedback for all verbal orders and being alert to �idents waiting to happen.” Other opportunities are broader in focus or address the work environment and may require clinical leadership and changing the workplace culture: simplifying processes to reduce handoffs and standardizing protocols developing and participating in multidisciplinary team training involving patients in their care and being receptive to discussions about errors and near misses by paying respectful attention when any member of the staff challenges the safety of a plan or a process of care.

However, large, complex problems require thoughtful, multifaceted responses by individuals, teams, and organizations. That is, preventing errors and improving safety require a systems approach to the design of processes, tasks, training, and conditions of work in order to modify the conditions that contribute to errors. Fortunately, there is no need to start from scratch. The IOM report included some guidance based on what was known at the time, and other specific evidence has accumulated since then that can be put in practice today. Designing for safety requires a commitment to safety, a thorough knowledge of the technical processes of care, an understanding of likely sources of error, and effective ways to reduce errors.

A Report From the Trenches—Systems, not Shame

These types of questions are by no means unusual. Partly because of its sheer complexity and the number of different individuals with different training and approaches, health care is prone to harm from errors𠅎specially in operating rooms, intensive care units (ICUs), and emergency departments where there is little time to react to unexpected events𠅊nd consequences can be very serious. Although most early studies focused on the hospital setting, medical errors present a problem in all settings, including outpatient surgical centers, physician offices and clinics, nursing homes, and the home, especially when patients and families are asked to use increasingly complicated equipment.

Patients should not be harmed by the health care system that is supposed to help them, but the solution does not lie in assigning blame or urging health professionals to be more careful. In what seems to be a simple example, an ICU nurse was wheeling a patient on a gurney to radiology when his knee struck a fire extinguisher hanging on the wall, resulting in the patient needing extra care. In response, the nurse may have been scolded by her supervisor and told to be more careful, or punished in some other way everyone would feel the problem had been solved. Yet, would that make the hospital safer? Would it prevent other events that are similar but slightly different in circumstances from happening with other staff and patients in other units? The answer is an emphatic no.

Improving safety, arises from attention to the often multiple latent factors that contribute to errors and in some cases, to injury. In the above example, such factors included: 1) the nurse having to move the patient herself because transport had never arrived 2) a change in hospital policy, so that only one instead of two people guide gurneys 3) the failure to mount the fire extinguisher in a recessed niche 4) the decision to transport a seriously ill patient rather than having mobile equipment come to him, requiring extra “handoffs” and opportunities for injury and 5) poor gurney design, making steering difficult, and possibly still other factors.

The IOM’s Four-Part Message

The IOM committee sought what could be learned from other disciplines and applied in health care by clinical and administrative leadership. It described actions that health care professionals can take now in their own institutions, whether they are new trainees, experienced clinical leaders, or instructors. The major thrust of the report was a four-part plan, intended to create financial and regulatory incentives to create a safer health care system and a systematic way to integrate safety into the process of care (the focus of this chapter). The four parts of the IOM recommendations are described below:

The committee recognized that some actions could be taken at the national level as described in the recommendations contained in Parts 1𠄳. Yet if patient safety were really to improve, the committee knew it would take far more than reporting requirements and regulations. Creating and sustaining a culture of safety (Part 4) is needed, which would require continuing local action by thousands of health care organizations and the individuals working in these settings at all levels of authority. Hospital leadership must provide resources and time to improve safety and foster an organizational culture that encourages recognition and learning from errors. A culture of safety cannot develop without trust, keen observation, and extensive knowledge of care processes at all levels, from those on the front lines of health care to those in leadership and management positions.


Causes

We don't yet know exactly what causes cognitive dysfunction in these conditions, but we have a lot of theories about possible contributing factors, including:

  • Sleep that isn't restful or restorative
  • Mental distraction due to pain
  • Overexertion in ME/CFS as a consequence of post-exertional malaise
  • Medications used to treat pain
  • Medications used for treating FMS and ME/CFS
  • Abnormal blood flow to some areas of the brain
  • Abnormal connectivity patterns between different regions of the brain
  • Abnormal function of certain brain chemicals (neurotransmitters)
  • Premature aging of the brain

In FMS, fibro fog generally is worse when pain is worse. In both FMS and ME/CFS, it can be exacerbated when you're especially fatigued, anxious, under pressure, or dealing with sensory overload.

Depression, which is common in FMS and ME/CFS, also is associated with cognitive dysfunction. Some studies, however, show that the severity of brain fog in these conditions is not related to symptoms of depression.


Anthropomorphism

Sometimes you cannot easily find the right wording in order to explain a cause and effect relationship, or you may not understand the concept well enough in order to write an explanation. Anthropomorphism is a type of oversimplification that helps the writer avoid a real explanation of a mechanism. A couple of examples should make the point for you.

The thought behind the statement is correct, but the statement does not represent the correct mechanism. Sodium has no free will. It tends to move toward the compartment with lower concentration because the probability of a sodium ion moving through a channel on the more concentrated side of the membrane exceeds the probability that an ion will move through a channel on the less concentrated side. If you don't want to explain the principle behind osmosis, you can simply state that osmotic pressure tends to drive sodium from the more highly to less highly concentrated side of a membrane.


6. TRACERT: Trace Route

TRACERT is a fascinating Windows Command to use. If you’re ever curious to see the path your internet traffic takes to get from your browser to a remote system like Google servers, you can use TRACERT to see it.

The command stands for “Trace Route”, which sends packets out to a remote destination (server or website), and provides you with all of the following information:

  • Number of hops (intermediate servers) before getting to the destination
  • Time it takes to get to each hop
  • The IP and sometimes the name of each hop

TRACERT can reveal how the routes of your internet requests change depending where you’re accessing the web. It also helps with troubleshooting a router or switch on a local network that may be problematic.


Acknowledging, Paraphrasing, and Quoting Sources

When you write at the college level, you often need to integrate material from published sources into your own writing. This means you need to be careful not to plagiarize: “to use and pass off (the ideas or writings of another) as one’s own” (American Heritage Dictionary) or, in the words of the University of Wisconsin’s Academic Misconduct guide, to present “the words or ideas of others without giving credit” (“Plagiarism,” ¶ 1). The University takes plagiarism seriously, and the penalties can be severe.

This handout is intended to help you use source materials responsibly and avoid plagiarizing by (a) describing the kinds of material you must document (b) illustrating unsuccessful and successful paraphrases (c) offering advice on how to paraphrase and (d) providing guidelines for using direct quotations.

What You Must Document

If you use an author’s specific word or words, you must place those words within quotation marks and you must credit the source.

Information
and Ideas

Even if you use your own words, if you obtained the information or ideas you are presenting from a source, you must document the source.

Information: If a piece of information isn’t common knowledge (see #3 below), you need to provide a source.

Ideas: An author’s ideas may include not only points made and conclusions drawn, but, for instance, a specific method or theory, the arrangement of material, or a list of steps in a process or characteristics of a medical condition. If a source provided any of these, you need to acknowledge the source.

Common Knowledge

You do not need to cite a source for material considered common knowledge.

General common knowledge is factual information considered to be in the public domain, such as birth and death dates of well-known figures, and generally accepted dates of military, political, literary, and other historical events. In general, factual information contained in multiple standard reference works can usually be considered to be in the public domain.

Field-specific common knowledge is “common” only within a particular field or specialty. It may include facts, theories, or methods that are familiar to readers within that discipline. For instance, you may not need to cite a reference to Piaget’s developmental stages in a paper for an education class or give a source for your description of a commonly used method in a biology report–but you must be sure that this information is so widely known within that field that it will be shared by your readers.

If in doubt, be cautious and cite the source. And in the case of both general and field-specific common knowledge, if you use the exact words of the reference source, you must use quotation marks and credit the source.

The way that you credit your source depends on the documentation system you’re using. If you’re not sure which documentation system to use, ask the course instructor who assigned your paper. You can pick up a Writing Center handout or check our Web site (www.wisc.edu/writing) for the basics of several commonly used styles (American Political Science Association, APSA American Psychological Association, APA Chicago/Turabian Council of Biology Editors, CBE Modern Language Association, MLA and Numbered References).

Sample Paraphrases—Unsuccessful and Successful

Paraphrasing is often defined as putting a passage from an author into “your own words.” But what are your own words? How different must your paraphrase be from the original? The paragraphs below provide an example by showing a passage as it appears in the source (A), two paraphrases that follow the source too closely (B and C), and a legitimate paraphrase (D). The student’s intention was to incorporate the material in the original passage A into a section of a paper on the concept of “experts” that compared the functions of experts and nonexperts in several professions.

A. The Passage as It Appears in the Source (indented to indicate a lengthy direct quotation)

Critical care nurses function in a hierarchy of roles. In this open heart surgery unit, the nurse manager hires and fires the nursing personnel. The nurse manager does not directly care for patients but follows the progress of unusual or long-term patients. On each shift a nurse assumes the role of resource nurse. This person oversees the hour-by-hour functioning of the unit as a whole, such as considering expected admissions and discharges of patients, ascertaining that beds are available for patients in the operating room, and covering sick calls. Resource nurses also take a patient assignment. They are the most experienced of all the staff nurses. The nurse clinician has a separate job description and provides for quality of care by orienting new staff, developing unit policies, and providing direct support where needed, such as assisting in emergency situations. The clinical nurse specialist in this unit is mostly involved with formal teaching in orienting new staff. The nurse manager, nurse clinician, and clinical nurse specialist are the designated experts. They do not take patient assignments. The resource nurse is seen as both a caregiver and a resource to other caregivers. . . . Staff nurses have a hierarchy of seniority. . . . Staff nurses are assigned to patients to provide all their nursing care. (Chase, 1995, p. 156)

Critical care nurses have a hierarchy of roles. The nurse manager hires and fires nurses. S/he does not directly care for patients but does follow unusual or long-term cases. On each shift a resource nurse attends to the functioning of the unit as a whole, such as making sure beds are available in the operating room, and also has a patient assignment. The nurse clinician orients new staff, develops policies, and provides support where needed. The clinical nurse specialist also orients new staff, mostly by formal teaching. The nurse manager, nurse clinician, and clinical nurse specialist, as the designated experts, do not take patient assignments. The resource nurse is not only a caregiver but a resource to the other caregivers. Within the staff nurses there is also a hierarchy of seniority. Their job is to give assigned patients all their nursing care.

Notice that the writer has not only “borrowed” Chase’s material (the results of her research) with no acknowledgment, but has also largely maintained the author’s method of expression and sentence structure. The underlined phrases are directly copied from the source or changed only slightly in form. Even if the student-writer had acknowledged Chase as the source of the content, the language of the passage would be considered plagiarized because no quotation marks indicate the phrases that come directly from Chase. And if quotation marks did appear around all these phrases, this paragraph would be so cluttered that it would be unreadable.

Chase (1995) described how nurses in a critical care unit function in a hierarchy that places designated experts at the top and the least senior staff nurses at the bottom. The experts–the nurse manager, nurse clinician, and clinical nurse specialist–are not involved directly in patient care. The staff nurses, in contrast, are assigned to patients and provide all their nursing care. Within the staff nurses is a hierarchy of seniority in which the most senior can become resource nurses: they are assigned a patient but also serve as a resource to other caregivers. The experts have administrative and teaching tasks such as selecting and orienting new staff, developing unit policies, and giving hands-on support where needed.

This paraphrase is a patchwork composed of pieces in the original author’s language (underlined) and pieces in the student-writer’s words, all rearranged into a new pattern, but with none of the borrowed pieces in quotation marks. Thus, even though the writer acknowledges the source of the material, the underlined phrases are falsely presented as the student’s own.

D. A Legitimate Paraphrase

In her study of the roles of nurses in a critical care unit, Chase (1995) also found a hierarchy that distinguished the roles of experts and others. Just as the educational experts described above do not directly teach students, the experts in this unit do not directly attend to patients. That is the role of the staff nurses, who, like teachers, have their own “hierarchy of seniority” (p. 156). The roles of the experts include employing unit nurses and overseeing the care of special patients (nurse manager), teaching and otherwise integrating new personnel into the unit (clinical nurse specialist and nurse clinician), and policy-making (nurse clinician). In an intermediate position in the hierarchy is the resource nurse, a staff nurse with more experience than the others, who assumes direct care of patients as the other staff nurses do, but also takes on tasks to ensure the smooth operation of the entire facility.

The writer has documented Chase’s material and specific language (by direct reference to the author and by quotation marks around language taken directly from the source). Notice too that the writer has modified Chase’s language and structure and has added material to fit the new context and purpose—to present the distinctive functions of experts and nonexperts in several professions.

Perhaps you’ve noticed that a number of phrases from the original passage appear in the legitimate paraphrase in D above: critical care, staff nurses, nurse manager, clinical nurse specialist, nurse clinician, resource nurse. If all these were underlined, the paraphrase would look much like the “patchwork” in example C. The difference is that the phrases in D are all precise, economical, and conventional designations that are part of the shared language within the nursing discipline (in B and C, they’re underlined only when used within a longer borrowed phrase). In every discipline and in certain genres (such as the empirical research report), some phrases are so specialized or conventional that you can’t paraphrase them except by wordy and awkward circumlocutions that would be less familiar (and thus less readable) to the audience. When you repeat such phrases, you’re not stealing the unique phrasing of an individual writer, but using a common vocabulary shared by a community of scholars.

Some Examples of Shared Language You Don’t Need to Put in Quotation Marks

Conventional designations: e.g., physician’s assistant, chronic low-back pain

Preferred bias-free language: e.g., persons with disabilities

Technical terms and phrases of a discipline or genre: e.g., reduplication, cognitive domain, material culture, sexual harassment

How to Paraphrase

  1. When reading a passage, try first to understand it as a whole, rather than pausing to write down specific ideas or phrases.
  2. Be selective. Unless your assignment is to do a formal or “literal” paraphrase,* you usually don’t need to paraphrase an entire passage instead, choose and summarize the material that helps you make a point in your paper.
  3. Think of what “your own words” would be if you were telling someone who’s unfamiliar with your subject (your mother, your brother, a friend) what the original source said.
  4. Remember that you can use direct quotations of phrases from the original within your paraphrase and that you don’t need to change or put quotation marks around shared language (see box above).

*See Spatt (1999), pp. 99-103 paraphrase is used in this handout in the more common sense of a summary-paraphrase or what Spatt calls a “free paraphrase” (p. 103).

  1. Look away from the source then write.
    Read the text you want to paraphrase several times—until you feel that you understand it and can use your own words to restate it to someone else. Then, look away from the original and rewrite the text in your own words.
  2. Take notes.

Take abbreviated notes set the notes aside then paraphrase from the notes a day or so later, or when you draft.

If you find that you can’t do 1 or 2, this may mean that you don’t understand the passage completely or that you need to use a more structured process until you have more experience in paraphrasing. The method below is not only a way to create a paraphrase but also a way to understand a difficult text.

For example, consider the following passage from Love and Toil (a book on motherhood in London from 1870 to 1918), in which the author, Ellen Ross, puts forth one of her major arguments:

Love and Toil maintains that family survival was the mother’s main charge among the large majority of London’s population who were poor or working class the emotional and intellectual nurture of her child or children and even their actual comfort were forced into the background. To mother was to work for and organize household subsistence. (p. 9)

Begin by starting at a different place in the passage and/or sentence(s), basing your choice on the focus of your paper. This will lead naturally to some changes in wording. Some places you might start in the passage above are “The mother’s main charge,” “Among the . . . poor or working class,” “Working for and organizing household subsistence,” or “The emotional and intellectual nurture.” Or you could begin with one of the people the passage is about: “Mothers,” “A mother,” “Children,” “A child.” Focusing on specific people rather than abstractions will make your paraphrase more readable.

At this stage, you might also break up long sentences, combine short ones, expand phrases for clarity, or shorten them for conciseness, or you might do this in an additional step. In this process, you’ll naturally eliminate some words and change others.

Here’s one of the many ways you might get started with a paraphrase of the passage above by changing its structure. In this case, the focus of the paper is the effect of economic status on children at the turn of the century, so the writer begins with children:

Children of the poor at the turn of the century received little if any emotional or intellectual nurturing from their mothers, whose main charge was family survival. Working for and organizing household subsistence were what defined mothering. Next to this, even the children’s basic comfort was forced into the background (Ross, 1995).

Now you’ve succeeded in changing the structure, but the passage still contains many direct quotations, so you need to go on to the second step.

Use synonyms or a phrase that expresses the same meaning.

Leave shared language (box, p. 3) unchanged.

It’s important to start by changing the structure, not the words, but you might find that as you change the words, you see ways to change the structure further. The final paraphrase might look like this:

According to Ross (1993), poor children at the turn of the century received little mothering in our sense of the term. Mothering was defined by economic status, and among the poor, a mother’s foremost responsibility was not to stimulate her children’s minds or foster their emotional growth but to provide food and shelter to meet the basic requirements for physical survival. Given the magnitude of this task, children were deprived of even the “actual comfort” (p. 9) we expect mothers to provide today.

You may need to go through this process several times to create a satisfactory paraphrase.

Using Direct Quotations

Use direct quotations only if you have a good reason. Most of your paper should be in your own words.

· To show that an authority supports your point

· To present a position or argument to critique or comment on

· To include especially moving or historically significant language

· To present a particularly well-stated passage

· whose meaning would be lost or changed if paraphrased or summarized

One of your jobs as a writer is to guide your reader through your text. Don’t simply drop quotations into your paper and leave it to the reader to make connections. Integrating a quotation into your text usually involves two elements:

  • A signal that a quotation is coming—generally the author’s name and/or a reference to the work
  • An assertion that indicates the relationship of the quotation to your text

Often both the signal and the assertion appear in a single introductory statement, as in the example below. Notice how a transitional phrase also serves to connect the quotation smoothly to the introductory statement.

Ross (1993), in her study of poor and working-class mothers in London from 1870-1918 [signal], makes it clear that economic status to a large extent determined the meaning of motherhood [assertion]. Among this population [connection], “To mother was to work for and organize household subsistence” (p. 9).

The signal can also come after the assertion, again with a connecting word or phrase:

Illness was rarely a routine matter in the nineteenth century [assertion]. As [connection] Ross observes [signal], “Maternal thinking about children’s health revolved around the possibility of a child’s maiming or death” (p. 166).

Incorporate short direct prose quotations into the text of your paper and enclose them in double quotation marks, as in the examples above. Begin longer quotations (for instance, in the APA system, 40 words or more) on a new line and indent the entire quotation (i.e., put in block form), with no quotation marks at beginning or end, as in the quoted passage from Chase on p. 2, A. Rules about the minimum length of block quotations, how many spaces to indent, and whether to single- or double-space extended quotations vary with different documentation systems check the guidelines for the system you’re using.

Punctuation with Quotation Marks

1. Parenthetical citations. With short quotations, place citations outside of closing quotation marks, followed by sentence punctuation (period, question mark, comma, semi-colon, colon):

Menand (2002) characterizes language as “a social weapon” (p. 115).

With block quotations, check the guidelines for the documentation system you are using. For APA, used in this handout, see sample A on p. 2, and sample C (the quotation from Ross) on p. 4.

2. Commas and periods. Place inside closing quotation marks when no parenthetical citation follows:

Hertzberg (2002) notes that “treating the Constitution as imperfect is not new,” but because of Dahl’s credentials, his “apostasy merits attention” (p. 85).

3. Semi-colons and colons. Place outside of closing quotation marks (or after a parenthetical citation).

4. Question marks and exclamation points.

Place inside closing quotation marks if the quotation is a question/exclamation:

Menand (2001) acknowledges that H. W. Fowler’s Modern English Usage is “a classic of the language,” but he asks, “Is it a dead classic?” (p. 114). [Note that a period still follows the closing parenthesis.]

Place outside of closing quotation marks if the entire sentence containing the quotation is a question or exclamation:

How many students actually read the guide to find out what is meant by “academic misconduct”?

5. Quotations within quotations. Use single quotation marks for the embedded quotation:

According to Hertzberg (2002), Dahl gives the U. S. Constitution “bad marks in ‘democratic fairness’ and ‘encouraging consensus’” (p. 90). [The phrases “democratic fairness” and “encouraging consensus” are already in quotation marks in Dahl’s sentence.]

Indicating Changes in Quotations

Use ellipsis points (. . .) to indicate an omission within a quotation–but not at the beginning or end unless it’s not obvious that you’re quoting only a portion of the whole.

Within quotations, use square brackets [ ] (not parentheses) to add your own clarification, comment, or correction. Use [sic] (meaning “so” or “thus”) to indicate that a mistake is in the source you’re quoting and is not your own.

Some Useful Sources on Paraphrasing and Summarizing

American heritage dictionary of the English language (4th ed.). (2000). Retrieved January 7, 2002, from www.bartleby.com/61/.

Bazerman, C. (1995). The informed writer: Using sources in the disciplines (5th ed). Boston: Houghton Mifflin.

Leki, I. (1995). Academic writing: Exploring processes and strategies (2nd ed.) New York: St. Martin’s Press, pp. 185-211.

Spatt, B. (1999). Writing from sources (5th ed.) New York: St. Martin’s Press, pp. 98-119 364-371.

Chase, S. K. (1995). The social context of critical care clinical judgment. Heart and Lung, 24, 154-162.

Hertzberg, H. (2002, July 29). Framed up: What the Constitution gets wrong [Review of R. A. Dahl, How democratic is the Constitution?]. New Yorker, pp. 85-90.

Menand, L. (2002, November 26). Slips of the tongue [Review of J. McMorris, The warden of English: The life of H. W. Fowler]. New Yorker, pp. 112-116.

Ross, E. (1993). Love and toil: Motherhood in outcast London, 1870-1918. New York: Oxford University Press.

Spatt, B. (1999). Writing from sources (5th ed.). New York: St. Martin’s Press.


G. GEOLOCATION DATA

1. I automatically collect geolocation information from users of my children’s app, but I do not use this information for anything. Am I responsible for notifying parents and getting their consent to such collection?

Yes. COPPA covers the collection of geolocation information, not just its use or disclosure.

2. What if I give my users a choice to turn off geolocation information? Do I still have to notify parents and get prior parental consent?

COPPA is designed to notify parents and give them the choice to consent. Therefore, it is not sufficient to provide such notification and choice to the child user of a website or service. If the operator intends to collect geolocation information, the operator will be responsible for notifying parents and obtaining their consent prior to such collection.

3. The Rule covers “geolocation information sufficient to identify street name and name of city or town.” What if my children’s app only collects coarse geolocation information, tantamount to collecting a ZIP code but nothing more specific?

COPPA does not require an operator to notify parents and obtain their consent before collecting the type of coarse geolocation services described. However, the operator should be quite certain that, in all instances, the geolocation information it collects is more general than that sufficient to identify street name and name of city or town.

4. The geolocation information I collect through my app provides coordinate numbers. It does not specifically identify a street name and name of city or town. Do I have to notify parents and get their consent in this instance? What if I collect other types of information, such as wireless network information, that can be used to determine precise location?

COPPA covers the collection of geolocation information “sufficient” to identify street name and name of city or town. COPPA applies even if the child is not asked to provide an actual street address. For example, COPPA would apply if an app collects the user’s longitude and latitude. Similarly, the Commission alleged that COPPA applied in United States v. InMobi Pte Ltd., where the company collected wireless network identifiers to infer the child’s precise location without providing notice or obtaining verifiable parental consent.


Research

Research-Based and Classroom Tested!

The design of Read, Write & Type is based on the best methods of reading instruction, and years of research in brain development. The program itself has been rigorously tested in elementary classrooms for over 10 years, and has produced significant reading improvement. RWT brings together the fundamental principles of reading instruction, with an emphasis on writing as a route to reading, in a program packed with visually exciting and engaging games and challenges. Prominent researchers, as well as our top teachers, report that the most effective reading instruction combines the best elements of whole language with those of phonics and phonemic awareness. In addition, the process of learning to read involves “breaking the alphabetic code”, that is, mastering the skills of both decoding the letters that make up words when reading, and encoding, putting together letters that make up words when writing. Reading methods that emphasize writing as a route to reading are powerful and revolutionary. And they are changing the way children learn.

Spanish-speaking Primary Students Boost Reading Skills in an After-School Computer Program using Read, Write & Type

In a project funded by the National Institute for Child Health and Human Development, (NICHD), sixteen Spanish-speaking 6-7 year olds attended an after-school class for 60 hours using the Read, Write & Type. Their progress in reading was compared to that of 16 comparable controls who either went home after school, or attended day-care or after-school tutoring. All 32 students were struggling to read and were in the lowest 40% of the class on reading scores. The groups were randomly assigned. Their home language was Spanish, and their Quick English Start (QSE) scores classified them with Limited English Proficiency (LEP). Mean QSE scores for the RWT group were 62 and for the Control Group were 65. At this school, primary students were receiving instruction in English with support in Spanish. All the teachers were bilingual but used primarily English in class except for brief clarification in Spanish. Read, Write & Type (RWT), is a 40-level software adventure that provides instruction in phonemic awareness, phonics, spelling, reading, writing, typing, and word processing. The RWT Learning System provides systematic instruction in all 40 phonemes while children sound-out and spell hundreds of words, phrases, and engaging stories. A second CD monitors progress and takes students to appropriate practice if they are not quite ready to move to the next level. The RWT group received 60-70 hours of instruction and all 16 students finished the 40 levels of the program. Classes with two teachers and one aide ran for one hour every day after school, 5 days/week. They used the new version of Read, Write & Type which can be set to provide Help and Instructions in Spanish. Spanish Help is optional and can be accessed by clicking on a Yellow Balloon. Spanish Instructions are provided anytime new instructions are provided in English. (When students are introduced to a new phoneme, or new concept — for example, when they are told that names start with capital letters, and are shown how to use the shift key to make a capital — all the instructions are in both English and Spanish). Classes started with warm-ups on the floor. Teachers used the Read, Write & Type lesson plans to structure the warm-ups. Students were introduced to a new Storyteller character and the sound that Storyteller represents. They worked on naming pictures that they would encounter in the computer program.. They generated sentences with the picture words. They analyzed the beginning, middle or ending sound of the words. They thought of other words with the same beginning sound. They discussed new vocabulary words. They practiced using the correct fingers on the paper keyboards as they sounded out each phoneme (chanting aloud in unison) in dictated words or short phrases like FAT CAT or RED JET. Then students spent about 30 minutes at the computer progressing through the 40 levels of the Read, Write & Type CD. After every 4 phonemes, they used the Spaceship Challenge CD to play games that assessed their progress in Phonics, Spelling, and Reading Comprehension. If their scores indicated that they were not ready to move to the next level, they clicked on the Bonus Blimp which took them automatically to activities they needed to practice before trying to pass the Spaceship games again. Students were tested before and after RWT with Woodcock-Johnson Word Attack (reading nonsense words) and Word Identification (reading words) in both Spanish (Munoz) and English.

Spanish Spanish English English
Word Word Word Word
Attack ID Attack ID
RWT Group
Before 10.4 21.1 7.18 23.6
After 16.9 27.8 16.7 33.4
Control Group
Before 10.8 20 7 25
After 14.4 24.8 12.6 29.6

Data were analyzed using an analysis of covariance to see if the posttest scores were significantly different when the pretest on that measure was used as the covariate. The RWT group showed significantly greater improvement on the English Word Attack (p < .02) and English Word Identification (p< .01), suggesting that an after-school program using the Read, Write & Type can be very effective at improving reading scores significantly for LEP primary students who are struggling to read. Because students received no direct instruction in Spanish reading skills, a more surprising finding was that the RWT group also improved more on the Spanish Word Attack (p<.01), suggesting that the development of phonemic awareness and phonics skills in English may affect those skills in Spanish as well. Spanish uses the same alphabet and is more phonetically regular than English, although a number of the phonemes, particularly vowel sounds, are different. But learning to segment words into their component phonemes (phonemic awareness) is the same process in both languages and one of the critical steps to reading.

Read, Write & Type Research Results: Florida State University

Dr. Joseph Torgesen, Distinguished Research Professor, and National Reading Expert, conducted a study at Florida State University with a group of first graders. Identified as at-risk for reading failure, they were evaluated over a 2-year period in a program using Read, Write & Type. The children showed large gains in reading skills from pre to post-tests, with very large gains in fluency and accuracy. Reading comprehension scores were also higher than expected based on the children’s general verbal ability. Click here to read Dr. Torgesen’s report.

Dr. Torgesen talks about the results: “We have been using Read, Write & Type to support small group instruction in reading for first grade children who are identified as at risk for reading failure. This project is being conducted with support from the National Institute of Child Health and Human Development. With its emphasis on phonological awareness, letter-sound knowledge and phonetic decoding in reading and spelling, Read, Write & Type is entirely consistent with recent discoveries that underline the importance of these skills to the growth of good reading ability.” “Read, Write & Type is an excellent example of the very best in computer applications to provide support for children learning to read. The program not only incorporates the most important principles of beginning reading instruction, but it has also brought them together in a package that is very engaging for children. The great strength of Read, Write & Type is that it provides explicit and systematic instruction in reading and spelling strategies in the context of meaningful and engaging writing and reading activities.

Read, Write & Type Research Results: The Writing Wagon Project

In a classroom study conducted at Millard School in Fremont, California, 94 first graders received instruction using Read, Write & Type in two 1-hour sessions per week for a seven month period. The performance of these children was compared to that of 50 first graders from a comparable elementary school who started with higher reading levels than the students from Millard School. The Millard School children achieved significantly higher end of year scores on phoneme blending, reading nonwords, and spelling. The Writing Wagon Project, carried out by Talking Fingers™ (CNS) and funded by the John S. and James L. Knight Foundation, delivered laptop computers for 56 hours (2 hours/week, November, 1996-June, 1997) to 94 first graders at Millard School in Fremont, California. Click here to see chart of results The 94 Millard first graders and a comparison group of 50 first graders at a nearby school were tested at the beginning and at the end of the project with the following tests: 1. Blending Phonemes, 2. Reading Nonwords, 3. Reading Words, 4. Elision, 5. Spelling. They were also tested at the end of the project with the following tests: 6. Woodcock-Johnson Word Attack, 7. Woodcock-Johnson Word Identification, 8. WRAT Spelling, 9. Typing. In summary, although the Comparison Group started out ahead on every test, the RWT Group scored significantly higher on Blending Phonemes, Reading Nonwords, and Spelling at the end of the project and made significantly greater improvement on all pre-post tests than the Comparison Group. They could find keys (keyboard and screen covered) with an average of 93% accuracy. Students in a small Special Day class (including several autistic students) also used the computers twice/week. Although they were not tested, the teacher reports that students made noticeable progress in reading, writing, and typing. These students were highly motivated to use the computer and were more focused while working at the computer with headphones than they were during teacher instruction. Conclusions: The Read, Write & Type approach boosted first grade reading and spelling scores significantly. In addition, students acquired a foundation of computer skills that will make their work more and more efficient as they continue through elementary school. This research suggests that if this approach were implemented widely, it could make a significant improvement in reading scores across the nation.

Read, Write & Type Research Results: Family Literacy Project

The Family Literacy Project, funded by the Knight Foundation, informally explored the effectiveness of Read, Write & Type with children and adults learning English as a second language. First and second graders used their new Read, Write & Type skills to help an adult family member learn English. A group of Vietnamese families and a group of Hispanic families participated for two nights a week in four 6-week sessions. This project was not designed to collect formal data, but both the adults and children found it very enjoyable. There were waiting lists for each session.

Los Altos School District # 1 in Reading After Using Read, Write & Type

Talking Fingers (CNS) carried out an extensive research and development program from 1990 to 1993 with the Read, Write & Type prototype (called Talking Fingers) at Downer Elementary School in Richmond, California, and Springer Elementary School, in Los Altos, California. As a result, in 1993 Talking Fingers (CNS) collaborated with the Los Altos School District, in Los Altos, California, on a $550,000 project to set up Talking Fingers writing labs in all six elementary schools in the district and to evaluate their effectiveness. The Los Altos District has since upgraded to labs using Read, Write & Type, and in 1999 took first place in all of California in 4th grade reading achievement. In an article in Education Week (March 31, 1999), Jane Croom, a parent of two children from the original project, related a personal story: her 7th grade son, who began using the program in first grade, now writes extensively and types 100 words per minute. Click here to learn more about Talking Fingers, Inc.


Medical Error Reduction and Prevention

Medical errors are a serious public health problem and a leading cause of death in the United States. It is challenging to uncover a consistent cause of errors and, even if found, to provide a consistent viable solution that minimizes the chances of a recurrent event. By recognizing untoward events occur, learning from them, and working toward preventing them, patient safety can be improved.

Part of the solution is to maintain a culture that works toward recognizing safety challenges and implementing viable solutions rather than harboring a culture of blame, shame, and punishment. Healthcare organizations need to establish a culture of safety that focuses on system improvement by viewing medical errors as challenges that must be overcome. All individuals on the healthcare team must play a role in making the provision of healthcare safer for patients and healthcare workers.

All providers know medical errors create a serious public health problem that poses a substantial threat to patient safety. Yet, one of the most challenging unanswered questions is "What constitutes a medical error?" The answer to this basic question has not been clearly established. Due to unclear definitions, “medical errors” are difficult to scientifically measure. A lack of standardized nomenclature and overlapping definitions of medical errors has hindered data analysis, synthesis, and evaluation.

There are two major types of errors:

Errors of omission occur as a result of actions not taken. Examples are not strapping a patient into a wheelchair or not stabilizing a gurney prior to patient transfer.

Errors of the commission occur as a result of the wrong action taken. Examples include administering a medication to which a patient has a known allergy or not labeling a laboratory specimen that is subsequently ascribed to the wrong patient.

Health care professionals experience profound psychological effects such as anger, guilt, inadequacy, depression, and suicide due to real or perceived errors. The threat of impending legal action may compound these feelings. This can also lead to a loss of clinical confidence. Clinicians equate errors with failure, with a breach of public trust, and with harming patients despite their mandate to “first do no harm.”

Fear of punishment makes healthcare professionals reluctant to report errors. While they fear for patients’ safety, they also dread disciplinary action, including the fear of losing their jobs if they report an incident. Unfortunately, failing to report contributes to the likelihood of serious patient harm. Many healthcare institutions have rigid policies in place that also create an adversarial environment. This can cause staff to hesitate to report an error, minimize the problem, or even fail to document the issue. These actions or lack thereof can contribute to an evolving cycle of medical errors. When these errors come to light, they can tarnish the reputation of the healthcare institution and the workers.

Some experts hold that the term “error” is excessively negative, antagonistic and perpetuates a culture of blame. A professional whose confidence and morale has been damaged as a result of an error may work less effectively and may abandon a career in medicine. Many experts suggest the term “error” should not be used at all. Due to the negative connotation, it is prudent to limit the use of the term “error” when documenting in the public medical record. However, adverse patient outcomes may occur because of errors to delete the term obscures the goal of preventing and managing its causes and effects.

Errors, no matter the nomenclature, typically occur from the convergence of multiple contributing factors. Public and legislative intolerance for medical errors typically illustrates a lack of understanding that some errors may not, in fact, be preventable with current technology or the resources available to the practitioner. Human factors are always a problem, and identifying errors permits improvement strategies to be undertaken. In particular, blaming or punishing individuals for errors due to systemic causes does not address the causes nor prevent a repetition of the error. The trend is for patient safety experts to focus on improving the safety of health care systems to reduce the probability of errors and mitigate their effects rather than focus on an individual’s actions. Errors represent an opportunity for constructive changes and improved education in health care delivery.

Governmental, legal, and medical institutions must work collaboratively to remove the culture of blame while retaining accountability. When this challenge is met, health care institutions will not be constrained from measuring targets for process improvement, including all errors, even with adverse outcomes.

Healthcare providers want to improve outcomes while reducing the risk of patient harm. Despite provider best efforts, medical error rates remain high with significant disability and death. Preventable medical errors contribute substantially to healthcare costs, including higher health insurance costs per person expenses. Only by health professionals working together will the cost and injury associated with medical errors be mitigated.

The Joint Commission Patient Safety Goals

The Joint Commission has introduced several patient safety goals to assist institutions and healthcare practitioners in creating a safer practice environment for patients and providers. The Joint Commission Goals include:

Identify patient safety dangers and risks

Identify patients correctly by confirming the identity in at least two ways

Improve communication such as getting test results to the correct person quickly

Prevent infection by hand-cleaning, post-op infection antibiotics, catheter changes, and central line precautions.

Prevent mistakes in surgery by making sure the correct surgery is done on the correct body part pause before surgery to double-check.

Use device alarms and make sure that alarms on medical equipment are heard and checked quickly.

Use medications correctly and safely, double-checking labeling and correctly passing on patient medicines to the next provider.

Label all medications, even those in a syringe. This should preferably be done in the area where the medications are prepared.

Take extra time with patients who have been prescribed anticoagulants and chemotherapeutic agents.

To prevent nosocomial infections, hand washing should be routine before and after visiting each patient.

While it is true that individual providers should be held accountable for their decisions, there is a growing realization that the majority of errors are out of the clinician's control. This being said, it remains difficult to change a culture of non-reporting.

Questions to consider include:

The potential for errors in healthcare is very high. Due to cost control measures, are individuals accountable, or are increased workload and staff fatigue the reason for errors?

Why report? Failure to report errors may subject clinicians to disciplinary action and increased risk for legal liability. Beneficence and nonmaleficence are ethical concepts that are violated when an error is not reported.

Practitioners often fear they will gain a reputation for committing mistakes and may not self-report. They know that mistakes and written warnings are often recorded in personnel files. Does the system need modification to decrease the penalty and encourage reporting?

Punishment may, in fact, reduce reporting errors because of the discipline and humiliation that is associated with repeated errors. Nevertheless, not addressing the problem increases the potential for more adverse events which places more patients at risk. Rather than placing blame, administrators and review boards need to move toward eliminating the blame-shame-discipline structure and move toward a prevention and education structure.

This culture incorporates both learning and improvement efforts that target system redesign and a reporting culture whereby all providers feel safe from retribution and, therefore, report issues about safety that help to constantly improve patient care and improve the safety of the system.

Patient safety has typically been outcome-dependent and the focus has been on preventing patients from experiencing adverse outcomes when receiving medical care. This may stem from Hippocrates, primum no nocere, or “First, do no harm.” While definitions in the literature are unclear, some general concepts can be garnered. Multiple similar definitions are available for each of these terms from various sources the health practitioner should be aware of the general principles and probable meaning.

Active errors are those taking place between a person and an aspect of a larger system at the point of contact.

Active errors are made by people on the front line such as clinicians and nurses. For example, operating on the wrong eye or amputating the wrong leg are classic examples of an active error.

An adverse event is a type of injury that most frequently is due to an error in medical or surgical treatment rather than the underlying medical condition of the patient. Adverse events may be preventable when there is a failure to follow accepted practice at a system or individual level.

Not all adverse outcomes are the result of an error hence, only preventable adverse events are attributed to medical error.

Adverse events can include unintended injury, prolonged hospitalization, or physical disability that results from medical or surgical patient management.

Adverse events can also include complications resulting from prolonged hospitalization or by factors inherent in the healthcare system.

These are errors in system or process design, faulty installation or maintenance of equipment, or ineffective organizational structure.

These are present but may go unnoticed for a long time with no ill effect.

When a latent error occurs in combination with an active human error, some type of event manifests in the patient. The active human error triggers the hidden latent error, resulting in an adverse event.

Latent errors are basically "accidents waiting to happen." A classic example is a hospital with several types of chest drainage sets, all requiring different connections and setups, yet not all frontline clinicians and nurses are familiar with the intricacies of each setup, creating the scenario for potential error.

The failure to complete the intended plan of action or implementing the wrong plan to achieve an aim.

An unintended act or one that fails to achieve the intended outcome.

Deviations from the process of care, which may or may not result in harm.

When planning or executing a procedure, the act of omission or commission that contributes or may contribute to an unintended consequence.

Failure to meet the reasonably expected standard of care of an average, qualified healthcare worker looking after a patient in question within similar circumstances. For example, the healthcare worker may not check up on the pathology report which led to a missed cancer or the surgeon may have injured a nerve by mistaking it for an artery.

Negligent Adverse Events

A subcategory of preventable, adverse events that satisfy the legal criteria used in determining negligence.

The injury caused by substandard medical management.

Any event that could have had an adverse patient consequence but did not.

Potential adverse events that could have caused harm but did not, either by chance or because someone or something intervened.

Near misses provide opportunities for developing preventive strategies and actions and should receive the same level of scrutiny as adverse events.

Never events are errors that should not ever have happened. A classic example of a never event is the development of pressure ulcers or wrong-site surgery. The National Quality Forum has identified the following as Serious Reportable Events:

Noxious Episode

Untoward events, complications, and mishaps that result from acceptable diagnostic or therapeutic measures that are deliberately instituted. For example, sending a hemodynamically unstable trauma patient for prolonged imaging studies instead of the operating room. The result could be a traumatic arrest and death.

The process of amelioration, avoidance, and prevention of adverse injuries or outcomes that arise as a result of the healthcare process.

Potentially Compensable Event

An error that could potentially lead to malpractice claims.

An event due to medical management that resulted in disability, and, subsequently, a prolonged hospitalization.

A deficiency or decision that, if corrected or avoided, will eliminate the undesirable consequence.

Common root causes include:

Changes in mental acumen including not seeking advice from peers, misapplying expertise, not formulating a plan, not considering the most obvious diagnosis, or conducting healthcare in an automatic fashion.

Communication issues, having no insight into the hierarchy, having no solid leadership, not knowing whom to report the problem, failing to disclose the issues, or having a disjointed system with no problem-solving ability.

Deficiencies in education, training, orientation, and experience.

Inadequate methods of identifying patients, incomplete assessment on admission, failing to obtain consent, and failing to provide education to patients.

Inadequate policies to guide healthcare workers.

Lack of consistency in procedures.

Inadequate staffing and/or poor supervision.

Technical failures associated with medical equipment.

No one prepared to accept blame or change the system.

The Joint Commission defines a "sentinel event" as “any unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. The phrase 'or the risk thereof' includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.” (The Joint Commission, 2017). Sentinel events are so-called because once discovered, they frequently indicate the need for an immediate investigation, discovery of the cause, and response.

Extent of the Challenge

Approximately 400,000 hospitalized patients experience some type of preventable harm each year .

Depending on the study, medical errors account for over $4 billion per year.

Medical errors cost approximately $20 billion a year.

Medical errors in hospitals and clinics result in approximately 100,000 people dying each year.

Medical errors typically include surgical, diagnostic, medication, devices and equipment, and systems failures, infections, falls, and healthcare technology.

Missed diagnoses or injuries from medication are common in outpatient settings.

Most malpractice claims in hospitals are related to surgical errors, whereas most claims for outpatient care are related to missed or late diagnosis.

Slightly more than half of the paid malpractice claims are related to outpatient care.

To decrease overhead, hospitals often reduce nursing staff staffing of RNs below target levels is associated with increased mortality.