The Story of Apollo and Marsyas

Analysis of Differnt Forms of Liberty - 1723 Words

The concept of liberty is important to this very day. Liberty initially means to be fundamentally free within ones society from any types of oppression, either from higher authority or from having different form ideologies that can be political or social. Liberty is a form of power that lets one act on their sets and values. In this paper, concept of liberty will be discussed on behalf of two philosophers, John Locke and Jean- Jacques Rousseau. Although liberty provides one to act as they please, there can be different forms of liberty, which are developed naturally by the state of nature and socially through development of human reasoning; state of nature is based on absolute freedom, while socially liberty is restricted. Firstly, John†¦show more content†¦One may destroy an individual if he takes away ones liberty where he makes him into a slave. This compels the individual to hurt or kill that person because that individual is taking the individual preservation, where t hey do not want to be controlled by any one and have their own way of life. For one not to kill another individual that individual also has to demonstrate that he is not enforcing power over him. For example, Locke claims, â€Å"But when the actual force is over, the state of war ceases between those that are in the society, and are equally subjected to fair determination of the law.†(Locke, 1690, p. 15). For this reason, in a civil society if the force to kill by both parties is over and one has conducted a crime, they can be prosecuted for the crime they have done, and prevent future occurrence of this type of event to happen again. Thus, state of war generally means state of conflict, where if one is threaten by any way they have the right to protect themselves by any means necessary even killing. If the conflict has stopped between either conflicting individuals or groups they have the right to have a trail to prosecute that individual or group that was threatening their liberty and preventing this type of conflict to take place again. There are two different forms of liberty one is the natural liberty that is provided by nature to be free from any type of power or authority. The second liberty is in a civil

Systems Analysis and Design Free Essays

ACME Financial is a fast growing company that owes part of its growth to several recent acquisitions. ACME Financial now wants to consolidate the companies’ information technology resources to eliminate redundancy and share information among the new companies. The Chief Information Officer (CIO) has oversight responsibility for the project and has hired Client/Servers R Us to develop the architecture for the new corporate information system. We will write a custom essay sample on Systems Analysis and Design or any similar topic only for you Order Now Joe Consultant of C/S R Us presented 3 client/server designs to the CIO and is requesting the CIO to select one. The CIO is not sure which middleware design is best for the company’s goals. The CIO has asked Chris Consultant to present the advantages and disadvantages for each of the alternatives. Background ACME Financial Incorporated (AF Inc. ) is an investment banking company that provides an on-line service that allows their clients to access account and market information. ACME Financial Inc. recently acquired several small and medium sized companies throughout the country, each with their own financial and accounting systems. Almost all of the companies have developed their own application software for their analysts’ use in their daily jobs, but only a few provided on-line account service. The analytical tools rely on near-real time market data and historical market data. The CIO wants to consolidate the financial and accounting information into a corporate information system that can support decision support applications for corporate management. Naturally, since the computer hardware is different for different companies, the CIO expects to upgrade the hardware to accommodate the new Information Technology (IT) system. The CIO will select the best analytical software as the standard software used by all company analysts. Each local site will be expected to provide an on-line service for their customers. Customers will be given the necessary application software to access their account information. Finally, ACME Financial has developed special data mining software that gives them a competitive advantage. AF Inc. offers their customers investment advice based on the information derived by the data mining software. Each account manager receives the information and then provides tailored recommendations  to each customer based on their portfolio. System Requirements The following list of system requirements reflects the system’s priorities (listed roughly in order of priority): 1. Availability: The CIO’s number one priority is high availability. AF Inc. markets their reliability and feels that most clients choose them for their dependability. The CIO wants to maximize the system’s availability. To achieve high availability, if a regional office cannot provide support then a customer must always have access to the on-line service through a different office. 2. Data Integrity: The requirement for data integrity varies within the system. The most important data are customer’s transactions. It is essential that a customer’s transaction is never lost and the system must guarantee that each transaction is completed. In contrast, data lost from the high data rate inputs, such as Reuter’s and the NYSE, are easily recovered during the each broadcast so it is not critical if some data are lost during a broadcast. 3. Performance: Financial markets are highly volatile; time sensitivity of data is measured in minutes. Millions can be lost if information is delayed getting to the analysts. The system must be able to support information broadcast throughout the network. 4. Security: The CIO is concerned about the security of the data mining software and the information produced by the data mining software. The Chief Executive Officer thinks the data mining information software provides a competitive advantage for the company. If an unauthorized user had access to the information they could steal the data mining applications or steal the information produced by the data mining software. In either case, the perpetrator could make the same investment recommendations as AF Inc. account managers. Therefore, if competitors had access to the information the results could be financially devastating to the company. The CIO is concerned that a competitor could pose as a customer and hack into the highly sensitive information through his on-line service account. 5. Growth: The CIO envisions an incremental migration process to install the new system due to the magnitude of the change. Also, he expects that AF Inc. will continue to grow and acquire more companies. The CIO wants to be able to develop more application software as new customer services are added. The CIO also wants to add more near-real time information sources to  the system. 6. Backup and Recovery: The CIO understands that the system will encounter problems from time to time. A key factor in determining the system’s success is how quickly the system can recover from a failure. Backup and recovery must be smooth and non-disruptive. One way to ensure that the system can easily recover from a system crash is to make sure the data is duplicated elsewhere on the system. The corporate database is the primary back up for each of the regional offices. Configuration Each local office (Northeast, Northwest, Southeast, Southwest) has accesses a regional information hub. Local offices use client software to access the local application server. These application servers access the local databases for almost all of the information needed on a daily basis. For access to information needed less frequently the application software should access the central database at corporate headquarters. Each regional database has only the subset of information that is relevant for its area, whereas the corporate headquarters maintains all of the information from each region as well as data that is unique to corporate applications, such as additional accounting and company financial information. The corporate office is also responsible for the data mining software and information. Each of the regional databases is connected with high capacity links to the corporate database. Finally, the corporate office receives information from Reuter’s, NYSE, NASDAQ, and other financial markets. The information flow fluctuates daily from 30 – 40 KBps to 4 – 5 MBps. Twenty-five percent of the information is immediately broadcast to the regional offices to support the on-line account service. All the information is filtered and stored in the database. Architectural Alternatives Alternative I: The Database Management System This alternative takes advantage of the extended functionality provided by the popular relational database management companies, such as Oracle and Sybase. All information is delivered into the system where it is immediately stored into one of the databases. The relational database management software is responsible for the distribution of information throughout the system. Clients communicate with the databases through Standard Query Language (SQL). Corporate and regional databases are kept synchronized using features supplied by the RDBMS software. Transactions are guaranteed by using special Transaction Processing Software. The vendor-supplied RDBMS software is responsible for back-up and recovery of all the databases. Data security is handled at the row level within each database. This means that clients can only receive records for which their user has permission. Existing application software may have to be modified to use SQL. Alternative II: Common Object Request Broker Architecture (CORBA) This solution depends on CORBA to tie together the clients and databases. CORBA is responsible for distributing data across the system. The RDBMS software is still responsible for the back-up and recovery, but the databases are kept synchronized using CORBA as the primary transport mechanism for the data. Clients, application servers, and databases communicate to each other through CORBA’s transport mechanism. Existing application software would be wrapped in IDL to communicate with other applications. Special near-real time handling application software would send the information to each of the regional offices where it would be directed to clients that subscribe to the information. Alternative III: Message and Queuing (MQ) The message and queuing design uses commercial M Q software combined with a transaction processing product to ensure customer’s transactions are completed. Dec Message Queue and MQ Series are some of the leading products for messaging and queuing software. Clients communicate to other entities using messages. Messages are deposited in queues and the message and queuing middleware is responsible for message distribution to the appropriate clients. The software applications will be modified to send and receive messages from queues. Questions to Answer (Total 100 points) The case study must be discussed covering the designs and these questions with your teammates, but your final write-up should be your collaborative work. Doing research on specific products for the assignment should certainly be a team activity. The total length of the write-up should probably not exceed 5 pages. 1. Describe in more detail the architecture of each architectural alternative. To do this you will need to flesh out the specifics of the various parts. This will require some research on the  products indicated (or other comparable products that you locate). Note that some services are automatically provided when a particular product is purchased, while others must be developed to satisfy the system requirements. You should describe what services are automatically provided by the products, which services would need to be developed, and how services should be distributed across the network. (40 points) 2. Evaluate each of the alternatives against the system requirements, discussing the advantages and disadvantages of each. (You may assume that the hardware will support all solutions.) In your analysis you might consider issues such as which alternative gives the system developers the most flexibility, which alternative provides easiest maintenance, and which alternative requires the least modification to the current system. Other hints for system comparison are listed below. (40 points) 3. Prioritize each alternative or suggest a different solution if you think it superior to the presented alternatives. (20 points) Suggestions on how to proceed 1. There is not enough information to make an informed decision about each of the alternatives. As a team, allot a percentage of your time to discover which products offer what type of services. You do not have enough time to do a complete market survey so be selective. 2. If you depend only on marketing information you may find that the alternatives are equivalent. So you might want to go beyond the market literature in doing your research for this assignment. 3. As you do your analysis, pay particular attention to some of the following kinds of issues: a. How well does the architecture support the basic system functionality requirements? b. How much run time performance overhead does the architecture impose? c. How well will specific products handle the high volume of data? d. How will each architecture handle occasional peak loads? e. How easy is it to customize the system to new requirements? 4. In your analysis, when you are considering costs, you do not need to consider the actual product cost. (It may be impossible to get actual product costs anyway. ) Instead, evaluate cost with respect to the amount of customized software that will be necessary to implement each alternative, and how this might affect long-term maintenance costs, time to implement, flexibility, etc. How to cite Systems Analysis and Design, Papers

Hindsight Bias and its Effect

Question: What is "hindsight bias," and how might it affect. Answer: Hindsight bias is a psychological term that is used in order to explain individuals tendency to overstate their ability to predict the outcome that was not possible to be predicted beforehand. For example, a boy passes the examination with good marks and his mother says that she predicted that her son will pass the examination with good marks. Therefore, it can be said that hindsight bias is a psychological bias that influence the people to over-represent their ability to predict something. In 2004, it was identified that HealthSouth Corporation has conducted near about $4.6 billion accounting fraud. However, if the hindsight bias took place, then it might have been possible to protect the organization from this kind of accounting fraud. Hindsight bias is such a psychological ability that would have helped the internal auditors of HealthSouth Corporation and the higher financial authority of the company to predict the worst situation by identifying the financial ratios such as net margin, receivable turnover and assets turnover (Barry, 2009). Hindsight bias might have helped the higher authority to take proper decision and steps so that the accountants of the organization could improve their accounting calculations. Due to this, the financial ratios of the company might have been rechecked and the situation could be handled in better way (Weld, Bergevin Magarth, 2004). Therefore, the company might not have to pay the penalty for accounting fraud. This would have helped the organization to maintain their reputation in the marketplace. Reference list: Barry, K. (2009). HealthSouths Corporate Accounting Scandal: A Case Study in Fraudulent Financial Reporting. Journal of Accounting Faud-at-HealthSouth. Weld, L. G., Bergevin, M. Magarth, L. (2004). Anatomy of a Fianncial Fraud. Journal of CPA.

Leader Analysis Sheet Essays (500 words) - 1st Millennium

Leader Analysis Sheet Name of Leader: Justinian Lifespan: c. 482 AD - November 15th, 565 AD Title: Justinian the Great Country/region: Byzantine Empire Years in Power: 527 AD - 565 AD (38 Years) Political: Many former Byzantium lands were lost due to invasions. The Western half of the empire was broken off. The capital was moved to Constantinople. Contact and trade is basically cut off entirely from Western Europe. Social: The Byzantine Empire followed its own branch of Christianity, Orthodox Christianity. Orthodox Christianity was entirely cutoff from the papacy and its power. Economic: The byzantine empire had one of largest and wealthiest economies in the world. The economy was mainly influenced by trade with Constantinople being a major trading hub for the whole world. The Byzantine Empire was a bridge between Europe, Asia, Africa, and other Northern Lands. Agriculture was included but development was slow and there was no major production. Justinian was intent on bringing the Byzantine Empire to a Golden Age and making unified, prosperous, and vast. His goals were to construct a well-developed legal code and system, and conquer lost lands. He also aimed to Beatify Constantinople. -Justinian extended the Byzantine Empire dramatically. He extended the empire back into areas that had previously been part of the Western Roman Empire.-Justinian successfully codified Roman Law. He gathered all the laws, rules etc. and collected them as a base for Byantine law.-He constructed the building of the Hagia Sophia, an extremely elegant and beautiful Church that still stands today. Short-Term Effects: Almost immediately upon his accession Justinian inaugurated a policy of restoration of the Roman Empire, the western part of which had been lost in the barbarian invasions of the 5th century. The eastern front of the empire was secured by an "eternal peace" signed with Persia in 532. Internal unrest was crushed by the great general Belisarius. In 533 an imperial army set out against the Vandal kingdom in North Africa, which was reincorporated into the empire in 534. The following year another imperial army attacked the Ostrogoths in Italy; the Ostrogoths, however, resisted annihilation for another 20 years. A third campaign, undertaken against the Visigoths, reconquered southeastern Spain. By the emperor's death most of the former Roman territory around the Mediterranean Sea, except for Gaul and northern Spain, was again part of the empire, despite a resumption of the Persian war in 540 and gradual Slavic infiltration in the Balkans. Long-Term Effects: The centralized empire envisaged by Justinian required a uniform legal system. Therefore an imperial commission headed by the renowned jurist Trebonianus worked for ten years to collect and systematize existing Roman law. Their work was incorporated into the enormous Corpus Juris Civilis (Body of Civil Law), also called the Justinian Code, promulgated in 534 and kept up to date by the addition of new decrees, or Novellae. This formidable legislative codification still remains the basis for the law of most European countries. Simultaneously with this legal reform, attempts were made to rectify administrative abuses.

The Process of Information System in Apple

The Process of Information System in Apple Introduction Information Systems is a crucial component of many organizations. It is notable that information and communication within the corporate company remains an important aspect of its success. In addition, lack of information communication may present challenges to the decision makers.Advertising We will write a custom essay sample on The Process of Information System in Apple specifically for you for only $16.05 $11/page Learn More Apple is a technology-based organization with a global presence. Its activities include product development, production, assembling, selling, and supply chain management. However, Apple’s research and development has enabled it to retain the market leadership in innovation. Company Background Three people founded Apple as an incorporated company in April 1976. They included â€Å"Steve Jobs, Steve Wozniak, and Ronald Wayne† (Linzmayer 5). The company started with little financial investment that hindered its ability to compete effectively with other firms that were already large market players. The company managed to set up a new headquarter in California. The company’s original Apple II product had become the source of success since 1970. The product remained common with clients and enabled the company to develop its original customer base (Linzmayer 8). The company’s expansion has been unprecedented since then. It started selling computers in the international marketplace. The role that Steve Jobs played in research and development was critical for the generation of highly innovative and exciting products. The company grappled with operational and management challenges that were associated with communication within and outside environment (Daft, Jonathan and Hugh 114). Analysts have argued that the entry of new investors presented challenges with clarity in communication. The company focused on products and significantly ignored organizational functioning. The company c ompartmentalization initiatives were guided by product orientation rather than organizational functioning needs. The companys core activities are supported through diverse activities such as infrastructure, information systems, management of materials, and human resources (see figure 1) (Daft, Jonathan and Hugh 114). Figure 1: Apple Organizational Structure and Core ActivitiesAdvertising Looking for essay on business economics? Let's see if we can help you! Get your first paper with 15% OFF Learn More The company is highly dynamic in terms of altering the organizational structure to fit with activities. However, the latest organizational structure entails different positions as depicted in the diagram. The corporate structure favors the existence of departmental competencies as opposed to organizational functioning (Daft, Jonathan and Hugh 114). The leadership structure at Apple provides low-level managers with the task of ensuring innovations and direction in every department. The company also facilitates market leadership in other geographical locations through the creation of mid-level management positions. This helps the firm in enhancing leadership within different geographical locations in order to promote a localized market competitive advantage (Daft, Jonathan and Hugh 114). However, the corporate structure presents challenges to strategic communication. The structure creates a double reporting channel. This takes place through ensuring that organizational functioning matters are reported to corporate directors while operational issues are reported to regional directors (Daft, Jonathan and Hugh 114). Information Systems Management at Apple The corporate structure of Apple that comprise of the global presence and departmental level leadership presents a unique situation. The structure necessitates a type of information systems that can facilitate the distribution of appropriate communication through the right channels and in a timely manner. Furthermore, this is critical to promoting consistent and informed decision making at diverse levels. The right information systems can enhance proper communication. The company has a philosophy of being the leader in marketplace on matters related to innovativeness (Wade, Scott and Yogesh 399). The company also applies the same philosophy in its communication and information transfer. Apple manages its internal communication in a manner that enhances its superiority.Advertising We will write a custom essay sample on The Process of Information System in Apple specifically for you for only $16.05 $11/page Learn More The company has implemented virtual business designs that integrate communication and information management (Hamilton 58). The company has used virtualization as a factor in gaining an edge over competitors. The company has used intranet system that enables workers to gain all information they need at their workstations. Furthermo re, the system allows Apple to interact with external stakeholders such as suppliers (Monczka, 15). The company has created unrestricted information exchange system that virtually links suppliers to the product development team and the retail units. Furthermore, information exchange takes place between the retail unit and the customer service center. It is notable that customer service center are always equipped with information about suppliers and company product range (Monczka, 15). The customer center provides services to clients based on the virtually available information. This strategy has enabled Apple to maintain a value chain information exchange system that links different components on an end-to-end basis. The virtually available information in the company enables the reduction of costs involved in transferring information between the people who need it (Hamilton 58). Furthermore, it saves the time of the company and its staff for everything to do with information exchang e takes place virtually. The implementation of a computing utility system also helps Apple minimize costs because it limits the volume of assets that are used in information exchange (Gitman and Carl 506). The company has ensured a lean and efficient information management strategy. Recommendation The company should constantly work on improving its information security management. The expansion of the company means that the information it manages also escalates. The company’s use of software based information management presents potential challenges associated with hacking. Hacking activities are highly dynamic (Stair and George 30). Hackers can hack into the virtual information management system if its not well secured. Apple should focus on creating a robust and insecurity proof systems to enable it secure its information management system.Advertising Looking for essay on business economics? Let's see if we can help you! Get your first paper with 15% OFF Learn More Daft, Richard L, Jonathan Murphy, and Hugh Willmott. Organization Theory and Design. Andover: South-Western Cengage Learning, 2010. Print. Gitman, Lawrence J, and Carl D. McDaniel. The Future of Business: The Essentials. Mason, OH: Thomson South-Western, 2008. Print. Hamilton, Cheryl. Communicating for Results: A Guide for Business and the Professions. Belmont, CA: Thomson/Wadsworth, 2008. Print. Linzmayer, Owen W. Apple Confidential 2.0: The Definitive History of the Worlds Most Colorful Company. San Francisco, Calif: No Starch Press, 2004. Print. Monczka, Robert M. Purchasing and Supply Chain Management. Mason, OH: South-Western, 2009. Print. Stair, Ralph M, and George W. Reynolds. Principles of Information Systems. Australia: Course Technology Cengage Learning, 2012. Print Wade, Michael R, Scott L. Schneberger, and Yogesh K. Dwivedi. Information Systems Theory: Explaining and Predicting Our Digital Society, Vol. 1. New York, NY: Springer Science+Business Media, LLC, 2012. Print.

Information Technology Architectures Essay Example | Topics and Well Written Essays - 500 words - 2

Information Technology Architectures - Essay Example CORBA is the standard software that supports distributed objects. It is a complex and a more difficult to learn software than any other communication infrastructure. COBRA offers a lot of functionality such as, programming language independency and the operating system. On the other hand, CORBA possesses the binding power to arrange of standardized programming languages as a communication format (Papadopoulos, 2009). Among the advantages of CORBA process, is its level of maturity, CORBA developed by the Object Management Group and its standard is neither too lax nor too restrictive. CORBA does not endanger the interoperability of some products nor the portability and space for optimization. Therefore, it offers a real international tested and proven power, flexibility and performance. CORBA offers a modularization facility to write objects in different programming languages that provide a service to users that do not require details of implementation of the object(s). CORBA also offers a facility that allows different clients to use the same interface thus working together transparently (Papadopoulos, 2009). CORBA’s disadvantages include its architecture complexity and specification which do not give a clear implementation details. It offers vertical features, which target some users and applications, but not all technology users thus insufficient (Papadopoulos, 2009). Java2 Enterprise Architecture (J2EE) is a mainframe scale computing platform which made for large firms. It simplifies thin client tiered environment application development (Papadopoulos, 2009). It decreases the need for programming, and programmer education by enhancing the tier to perform many programming aspects automatically. The Java 2 Enterprise Architecture (J2EE) consists of a security model which protects data both in web-based application and also locally. It is portable since it consists of a write once and Run anywhere

Small Business Innovation Research Programs Case Study

Small Business Innovation Research Programs - Case Study Example Towards this direction, it is noted that ‘a framework based on wisdom rather than knowledge alone provides strategic options for paradigm development in the field of small business and entrepreneurship research’ (Mathys et al., 2005, 657) - a field similar with the one to which the article under examination refers. The current paper focuses on the analysis of the article ‘Technological Entrepreneurship and Small Business Innovation Research Programs’ by Kropp, Fredric, and Zolin, Roxanne. The above article was published in 2005 in the academic journal Academy of Marketing Science Review. In accordance with the authors’ statement, the above article focuses on ‘the conceptual role that government technology programs can play in facilitating the process of technological entrepreneurship’ (page 1). The case of the ‘Small Business and Innovation Research (SBIR) program - United States’ (page 1) is used as an example of the potential support of the stage to the small businesses. The article shows the various methods available to small businesses that are interested in using governmental programs for the development of their performance - it is also explained how these programs could lead to the increase of profitability of firms in various industrial sect ors. The overall effectiveness of these programs is criticized - the authors suggest potential measures that could be used by firms that need to improve their performance – either in the short or the long term – through relevant governmental programs. The value of the article cannot be doubted; however, there are a few points that should be reviewed. Suggestions are made and relevant criticism is developed making sure that any assumption is appropriately justified with reference to the text and to academic material with similar content. The authors use a specific theoretical model, the one created by Lumpkin and Dessin 1996 in order to show the effects of government programs on the improvement of performance of firms that operate in the technology sector – the special reference is made on the firms of small size.

Project Financial Risk Management followed in IT industry enhances the Research Paper

Project Financial Risk Management followed in IT industry enhances the success rates of Projects delivered - Research Paper Example Financial Risk Management in IT Introduction Risks management is in many ways the process of identification, assessment and prioritization of risks, which is then followed by the coordination of all economic resources necessary for the elimination or minimization, monitoring, and control of the probable impacts of uncertain events. It has been found that, risk can come from uncertainties in financial markets, legal liabilities, project failures, accidents, credit risks (Macomber 2003, p. 2). Studies indicate that, there are various project management standards, which have been under development in the project management institute, actuarial societies, ISO standards, and the national institute of standards and technology (Hodgson 2003, p.1). The approaches and objectives of hazard supervision vary greatly dependent on the hazard administration technique applied in the setting of a scheme administration.. In other studies however, hazard administration includes the ranking of the essen tial developments; hazards with the extreme loss are handled first and then the other hazard are handled in a descendent mode in order of precedence. It is pointed out that intangible management usually identifies new types of risks that have about a hundred percent probability but the management ignores because most organizations lack identification capabilities to handle such cases (King 2003, p. 2). It is recorded that relationship risk emanate when inefficient ways of collaboration is experienced. This type of hazard is known to reduce the efficiency of information workforces, effectiveness, service, excellence, product value, and excellence of earnings at the end. Thus, risk management is a subject or process that needs all manner of care to be successful. Literature review From organizational perspective, risks arise most often when businesses pursue opportunities in face of uncertainties, while being compelled by capabilities and cost. In most cases, a challenge comes when it comes to the process of finding a position based on the two dimensions, as it represents in essence itself a risk profile that may be appropriate for the initiative; acceptable to both internal and external stakeholders of the business in question. Studies affirm that, hazard and hazard administration are premeditated in nature. Regarding, information and technology studies show that, software projects have been recognized to be high-risk ventures, which are prone to many failures. Some studies argue that there are mainly two classes of risks; generic risks that are common to all projects, and project specific risks. In many cases, some of these hazards are easy to recognize and regulate or accomplish. However, in some cases, other risks are less obvious and thus very difficult to make predictions on their likelihood to occur and the impact they may cause at that time (Levine 2004, p. 32). The complication and difficulty in predictions comes because of numerous project proportions; structure, size, complexity, composition, novelty, long planning, and execution horizons. All these have a common influence on the modest of the scheme at the end; hus, any indeterminate discrepancy in this has fiscal implications. Therefore, risk management in information technology, especially software

A Sentinel Event Related To Nurse Fatigue Nursing Essay

A Sentinel Event Related To Nurse Fatigue Nursing Essay 12 hour shifts, extended work periods, voluntary and mandatory overtime, and excessive workloads are all factors that dangerously contribute to nurse fatigue, which has led to a number of medication errors and sentinel events (Rogers, Hwang, Scott, Aiken, Dinges, 2004). In the 2004 study by Rogers, Hwang, Scott, Aiken, Dinges, it was found that the longer the shift, the risks for errors increases. Also, when working longer than 17 hours without sleep, nurse fatigue has been shown to demonstrate the equivalence of being under the influence with a blood alcohol concentration of 0.05% (Garrett, 2008). The effects of fatigue on nurses includes problems such as: compromised problem-solving skills, decreased attention span, delayed reaction time, memory lapses, impaired communication, and inability to focus, which are all important for nurses to be aware of in order to provide quality and safe patient care (Warren Tart, 2008). The evidences and dangers of nurse fatigue linked to adverse events from the long work hours and cumulative days of extended work hours has been greatly recognized by The Joint Commission (TJC) issuing a sentinel event alert on December 14, 2011, regarding health care worker fatigue and patient safety (The Joint Commission, 2011). So, I will be discussing the following in the paper that includes: explanation of reviewable sentinel events, a specific sentinel event related to nurse fatigue, and its root cause analysis. Explanation of Reviewable Sentinel Events As defined by TJC, a sentinel event is an unexpected occurrence involving either death, serious physical or psychological harm, or the risk thereof that prompts the need for immediate investigation and response (Sentinel Events Policy and Procedures, 2012). But, for a sentinel event to be considered reviewable, it must meet any of the following criteria: the event resulting in an unanticipated death, coma, permanent loss of function, unrelated to the natural course of the patients illness or underlying condition, or the event is one of the following, but not limited to: suicide within 72 hours of being discharged from a 24 hour care setting rape, sexual abuse/assault elopement abduction (Sentinel Events Policy and Procedures, 2012). A Specific Sentinel Event Related to Nurse Fatigue On July 5, 2006, Jasmine Gant, a pregnant 16 year old high school student, arrived with her mother at St. Marys Hospital in Madison, Wisconsin at 9:30 A.M. for her scheduled induction (Smetzer, Baker, Byrne, Cohen, 2010). The Labor and Delivery (LD) nurse assigned to care for Ms. Gant that day was Julie Thao, 41 years old. Mrs. Thao had been working at St. Marys Hospital since 1993, and worked in the LD department for 15 years. The day before July 5, 2006, Mrs. Thao had voluntarily worked a double shift for a total of 16 hours or more to cover for the units short staff. Mrs. Thao was extremely fatigued by the end of her shift that ended at midnight. She spent the night at the hospital to avoid her hour long commute home and because she was due for her next shift at 7 A.M. So on the morning of July, 5, 2006, the very fatigued nurse Mrs. Thao started her shift caring for one expectant mother. When Ms. Gant presented at the LD unit later that morning, Mrs. Thao spent time with her and her mother completing the admission process that is done with every admitting patient. However, Mrs. Thao did not apply a bar-coded identification band to Ms. Gants arm at this time (Smetzer, Baker, Byrne, Cohen, 2010). When discussing pain management, Ms. Gant expressed the possibility of wanting to use epidural, which Mrs. Thao would relay the message to the obstetrician. At 11:30 A.M., Ms. Gants physician arrived to her room to rupture her amniotic membrane. The physician told Mrs. Thao that he planned to check back before determining with the patient the need for epidural. In the meantime, he had ordered Pitocin, Lactated Ringers (LR) solution, and intravenous (IV) penicillin to treat a strep infection that Ms. Gant had. While Mrs. Thao was in the room, the patient communicated to her that she was anxious about receiving epidural. So, Mrs. Thao thought it would be a good idea to retrieve epidural solution, Bupivacaine, to show the patient and in anticipation since the Anesthesiologist would get upset for not having it readily available. Now, St. Marys Hospital had just started transitioning and training the employees in using the newly installed bar coded medication administration system. Apparently, the hospital was currently having problems with it, so the nurses were instructed to give the medications when needed and document them manually. Well, Mrs. Thao bypassed the system to remove the Bupivacaine, which she also did not have authorization or permission to do so for that medication. Then, she gathered the LR solution and Pitocin before walking back into the patients room. On the way, another nurse handed her the IV penicillin. When Mrs. Thao entered the patients room, she sat the supplies on the counter and began to prepare and initiate the IV infusion. Carelessly, Mrs. Thao made the fatal mistake and grabbed the epidural solution instead of the penicillin, both looking very similar in appearance, administering it intravenously into Ms. Gants arm. Unknowingly of the mistake she had just done that would soon c ost her nursing career and her patients life, Mrs. Thao went on to rewinding the tape on the birthing process to play for the patient, her mother, and the babys father who had just showed up creating lots of tension. Within minutes, the patients mother terrifyingly screamed for mercy. At this point, her daughter was in respiratory distress, seizing, and into a cardiac arrest. The frantic nurse immediately called the rapid response team and code blue. Every effort was made to resuscitate Ms. Gant, but she remained asystolic. Ms. Gant was immediately taken to the operating room to have an emergency cesarean section where the physicians delivered an 8 pound healthy baby boy. The health care team continued resuscitating Ms. Gant, but was pronounced dead by 1:43 P.M. After ruling out several possible causes of her death, it was discovered minutes later that the infusing bag was the epidural solution, instead of the penicillin (Smetzer, Baker, Byrne, Cohen, 2010). Her colleagues reported that Mrs. Thao looked extremely fatigued, which possibly increased her likelihood of making the fatal medication error along with the omission to verify the five rights of medication administration. The Root Cause Analysis A root cause analysis (RCA) is a technique used to help identify the possibilities of causes that led to the end result. When a sentinel event occurs, the hospital is accountable to do a root cause analysis. The point of RCA is not to point out who is to blame. Thus, by conducting a RCA, it allows for a plan of action to prevent the same or similar incidents from occurring. The first part of the RCA is defining the problem or effect. Part two is determining why it happened with the cause and effect technique. Part three is generating solutions and implementing a plan of action to reduce the likelihood of the event from happening again. In the sentinel event above, the problem was a medication error by registered nurse (RN) Julie Thao that had resulted in the maternal death of 16 year old expectant mother, Jasmine Gant. The four cause categories formulated for this specific case are: people, work environment, equipment, and policies and procedures. The nurse Mrs. Thaos fatigued had a tremendous effect on the actions leading to the medication error. She had voluntarily worked a back to back shift of 16 hours or more the night before starting work again the next morning. She expressed the desire to go home halfway through her second shift, too. While taking care of Ms. Gant, the nurse was distracted while preparing the medications. Mrs. Thao reported that there was tension in her patients room when the babys father arrived, so she had intended to administer the IV penicillin and put on the educational video of the birthing process. The work environment of the LD unit that Mrs. Thao worked on was not well organized. The nurses did not directly communicate with the Anesthesiologist making it difficult to have the epidural ready upon their arrival. The unit was also short staffed with several nurses on temporary leave (Smetizer, Baker, Byrne Cohen, 2010). If Mrs. Thao had not worked second shift, they would have been inadequately staffed. The staff and managers did not strictly enforce and comply with the policies such as the identification bands and bar code medication administration system. So, the problems associated with the policies and procedures included the delay of the patients identification bar code band application, omission of verifying the five rights of medication administration, and retrieving the epidural before it was ordered. The issue with the delay of the patients identification band was that it took longer for the bands to be made with the new system. The staff and management were lenient and made it a norm to put it on the patient whenever it was a convenient time. However, Mrs. Thao confessed that she did not comply with the five rights of medication administration. Also, she retrieved the epidural before it was ordered to decrease her patients fear and in anticipation of early epidural. Retrieving the epidural in anticipation upon the Anesthesias arrival was a common practice on the LD floor because of the dissatisfaction expressed by some Anesthesiologist of it not being readily available. For equipment, there was the problem of the newly installed bar code medication administration system and the design of the bag of epidural solution and IV penicillin. The new systems constant problems created low rates on compliance on scanning IV bags, and nurses bypassing the system, which included safety features to prevent such errors from happening. The LD unit staff had inadequate training on troubleshooting the system, especially Mrs. Thao. Instead, management allowed them to hang the medications and document them manually. With the mistake of grabbing the wrong bag, Mrs. Thao had brought all the supplies including the two bags from the anteroom and sat them onto the counter near the patients bedside so that she can converse with the patient directly. The bag containing the epidural solution and the bag of the penicillin looked similar in size, but the epidural was slightly bigger. They were both clear solutions. The two bags both had orange label stickers, but the epidural b ag had an additional bright pink warning label. There is also a design flaw in the interconnectivity making the IV tubing compatible with accessing the epidural bag port like it does with the IV solutions (Smetizer, Baker, Byrne Cohen, 2010).

Workplace Violence and How to Prevent it Essay -- Workplace Health and

Workplace Violence and How to Prevent it The Workplace is considered a second home for many people because a work shift may range 8 to 12 hours daily. Based on that fact alone it is important to feel safe, comfortable and content in the workplace. Despite the differences in the public and private sector the mission, goals and objectives of any organization can be similar. For example, productivity, cost effectiveness, efficiency, profit or goods/services and the safety within the establishment is equally important. Unfortunately, the challenges that face management are increasing rapidly and during the past 2 decades "Violence in the Workplace" has become an increased fear among employers and employees. Violence in the Workplace can be defined as" (1) any problem related to the workplace or away from the workplace if it relates to the job" http://www.state.il.us/isp/viowkplc/vwpp1.htm. Violent incidents that may occur on site and violence that occurs away from the job but is job related. Types of job related violence away f rom the job may include telephone harassment, stalking and confrontations. Violence in the workplace has intensified from idle threats to homicides and the majority of assailants are reportedly domestic partners, strangers, customers or clients and employees. "Homicide was the third leading cause of occupational death from 1980 to 1985, accounting for 13 percent of all workplace deaths" (2) http://www.nsi.org/Tips/workdeth.txt. More recent data indicates that the statistics and fear is increasing and the level of safety is decreasing. The National Institute for Occupational Safety and Health (NIOSH), reports "nearly 7000 workers were victims of homicide in the workplace during the period of 1980 to 1989... ...ace". accessed October 17, 1999 available from http://www.workviolence.com ;Internet. Marianne Minor. "Preventing Workplace Violence; Positive Management Strategies". Crisp Publications, Park, Menlo, California, 1995, pg.20. Occupational Safety and Health Administration (OSHA). "Workplace Violence" available from http://www.osha-slc.gov/SLTC/workplaceviolence/index.html accessed November 19, 1999 Internet. Occupational Safety and Health Administration (OSHA). "Workplace Violence" available from http://osha.gov/oshinf/priorities/violence.html accessed on November 21, 1999; Internet. Robertson, Dirk. "Violence in your Workplace; How to Cope". Souvenir Press, London, 1993, pg. 19. Tyler, Mary P. "A Manager's Guide: Traumatic Incidents at the Workplace. U. S. Office of Personnel Management (OPM) 1993.