Submitted by Cinthia Ferreira Costa (cinthiac.costa@gmail.com) on 2018-09-03T13:17:52Z No. of bitstreams: 1 TA_Cinthia Costa_versão final.pdf: 765367 bytes, checksum: f616f7fa6b7603c5ba1ac56f1db7dfbf (MD5) / Approved for entry into archive by Simone de Andrade Lopes Pires (simone.lopes@fgv.br) on 2018-09-03T19:51:28Z (GMT) No. of bitstreams: 1 TA_Cinthia Costa_versão final.pdf: 765367 bytes, checksum: f616f7fa6b7603c5ba1ac56f1db7dfbf (MD5) / Approved for entry into archive by Suzane Guimarães (suzane.guimaraes@fgv.br) on 2018-09-04T14:41:02Z (GMT) No. of bitstreams: 1 TA_Cinthia Costa_versão final.pdf: 765367 bytes, checksum: f616f7fa6b7603c5ba1ac56f1db7dfbf (MD5) / Made available in DSpace on 2018-09-04T14:41:02Z (GMT). No. of bitstreams: 1 TA_Cinthia Costa_versão final.pdf: 765367 bytes, checksum: f616f7fa6b7603c5ba1ac56f1db7dfbf (MD5) Previous issue date: 2018-07-30 / A segurança do paciente é uma preocupação mundial e de alta prioridade na agenda da Organização Mundial da Saúde (OMS) e seus países membros. Nesse contexto, a gestão de incidentes nos serviços de saúde tem papel essencial para a redução de riscos e danos aos pacientes. Esta pesquisa teve como objetivo conhecer como é realizada a gestão de incidentes nos hospitais paulistanos e qual a visão dos gestores sobre a segurança do paciente como um fator estratégico e de competitividade. Foi realizada pesquisa qualitativa, por meio de entrevistas semiestruturadas com o auxílio de roteiro de entrevista em oito hospitais, sendo cinco privados e três filantrópicos no período de março e abril de 2018. A pesquisa demonstrou um maior número de organizações com sistema de notificação de incidentes informatizado, o crescimento dos serviços de atendimento ao cliente como referência para o contato do paciente ou familiar quando da ocorrência de um incidente e o papel da direção na informação ao paciente e familiar sobre os incidentes ocorridos. Considerando que o movimento pela segurança do paciente é relativamente recente no Brasil, o nível de maturidade da cultura de segurança dos hospitais entrevistados demonstrou ser positiva. O uso de indicadores aponta a valorização do tema dentre as preocupações da gestão e, em alguns casos, da alta direção. Pelas respostas dos entrevistados, é possível afirmar que a segurança do paciente faz parte da estratégia das organizações participantes deste estudo, demonstrando um cuidado corporativo de direcionar os esforços da qualidade e da segurança. / Patient safety is a global concern and hight priority on the schedule of the World Health Organization (WHO) and its member countries. In this context, incident management in health services plays a key role in reducing risks and damaging patients. This research had as objective to know how the management of incidents at the hospitals in São Paulo is and what the managers' view on patient safety as a strategic and competitive factor. A qualitative research of an exploratory nature was carried out, through semi-structured interviews in eight hospitals, five private and three philanthropic in the period of March and April of 2018. The research demonstrated the largest number of organizations with computerized incident reporting system, the growth of customer service as a reference for patient or family contact when an incident occurred, the role of management in patient information and familiarity with the incidents. Considering that the patient safety movement is relatively recent in Brazil, the level of safety culture maturity of the hospitals interviewed demonstrated to be positive. The use of indicators points out the appreciation of the theme among the concerns of management and, in some cases, top management. From the respondents' answers, it is possible to affirm that patient safety is part of the strategy of the organizations participating in this study demonstrating a care corporate effort to direct quality and safety efforts.

Device Management Applications are applications which are used to manage software on devices such as mobile phones. OMSI Forum provides such an application which is used to update the software on a phone. Software updates can be done at device management stations placed in stores or other service locations. Whenever a phone's software is updated, information about the update process is stored in a log. These logs can then be analyzed to generate statistics about updates such as the number of successful or failed updates or which faults that are common. This master thesis project solves the problem of manually collecting and compiling logs from several stores by making this process automatic. Rather than collecting logs manually, each device management station sends its logs to a centralized server which stores all collected logs in a database. This makes it possible to generate charts and statistics in a simple manner from a web application. This solution makes the analysis more e ective, allowing users to concentrate on analyzing data by removing the work task of collecting logs.

Introduction: Incident reporting systems have been implemented in health care for over a decade and contain reports of critical incidents (CI). These must be analyzed in order to suggest, implement and evaluate solutions for minimizing the risk of future CIs to occur, thereby increasing patient safety. Drug-related CIs (DRCI) are one type of CI which may represent up to 1/3rd of all CIs, therefore this CI-type is characterized in this study. Aim: To categorize and characterize DRCIs reported in the Critical Incident Reporting System North Rhine-Westphalia (CIRS-NRW). Materials & Methods: In this explorative, retrospective, descriptive study, 553 reports from the CIRS-NRW, reported between the 1st of January 2019 and the 15th of September 2021, were analyzed. These were categorized by setting, medication use process stage, ATC-code, patient age and look-alike, sound-alike (LASA), and then analyzed via descriptive statistics. Various subgroup analyses were also conducted. Results: DRCIs occurred mostly in the hospital (48,5%) and pharmacy (40,7%) settings, during the prescribing (33,8%) and administration (33,5%) of drugs and the ATC-codes N02 (9,4%), B01 (6,9%) and N05 (5,4%) were commonly involved. Patient age contained >50% missing data and LASA was involved in 16,5% of DRCIs. Subgroups were often small, likely resulting in low statistical power. Conclusion: By successfully characterizing the DRCIs, some potential areas of improvement for reducing future DRCIs were highlighted, however there are many more variables of relevance for patient safety than those analyzed in this study, underlining the need for further studies characterizing more DRCIs including additional variables.

Forskning visar att traditionella rotorsaksanalyser har begränsningar när det gäller att utreda händelser i komplexa system. För de komplexa system som utgör dagens moderna arbetsliv krävs att analyser sker på en övergripande systemnivå, organisationsnivå, där till exempel tekniska, organisatoriska och sociala faktorer som påverkar arbetssystemet beaktas. I takt med att rapporteringen av händelser och tillbud ökar blir mängden rapporter att hantera allt större, det krävs tekniska system och hjälpmedel för att bearbeta data. Är Informationssystem om Arbetsmiljö (IA) ett ärendehanteringssystem för att hantera enstaka ärenden eller går det att upptäcka trender och använda systemet förebyggande på en övergripande organisationsnivå i det systematiska arbetsmiljöarbetet? Syftet med studien var att visa om användningen av ett incidentrapporteringssystem ger ett företag möjlighet att analysera arbetsmiljöbrister ur ett systemperspektiv och på så sätt öka kunskapen om risker inom företaget. En kvalitativ fallstudie utfördes, på ett verkstadsföretag, med en abduktiv ansats med växling mellan empiri och teoretisk reflektion. Studien bygger på såväl data från IA-systemet som underlag från intervjuer av händelseansvariga på det studerade företaget samt en litteraturstudie. Analysen visar att IA-systemet stödjer analys ur ett Människa-Teknik-Organisation-perspektiv (MTO-perspektiv) men saknar en strikt taxonomi kopplad till förståelsen av bakomliggande orsaker till händelser. Det saknas stöd för att på ett tillförlitligt sätt analysera händelser på en övergripande system- eller organisationsnivå. Inkonsekvent kategorisering av incidentrapporter försvårar effektivt utnyttjande av incidentrapporteringssystem och utvärdering av analyser påverkas negativt. Ett alternativ skulle kunna vara att utöka IA-systemet med en textanalysdel som kan hantera fritext i databasen och söka efter nyckelord. Genom att kombinera fritextanalys med taxonomi kan trender påvisas ur en stor mängd data. / Research reveals traditional root cause analysis to have limitations when used to analyse incidents in complex systems. For complex systems like modern work life environment analysis is required to be carried out on overall system level, organisational level, where technical, organizational and social factors impacting the system of work are considered. As reporting of incidents and near misses are increasing, the corresponding number of reports to be handled are larger, which requires the assistance of technical systems in order to handle all data. Is Occupational Health and Safety Information System (IA-system) an incident reporting system just for single incidents or will it facilitate detection of trends to use the system for preventive actions on a higher organizational level to support systematic work environment management? The purpose of the study was to show whether the use of an incident reportingsystem gives a company the opportunity to analyse work environment deficiencies from a system perspective and thus increase knowledge about risks within the company. A qualitative case study was carried out, at a manufacturing company, with an abductive approach supported by switching between empirical and theoretical reflection. The study is based on data from the IA-system and interviews from people responsible for handling issues at the studied company as well as a literature study. The analysis shows that the IA-system supports analysis from a Human-Technology-Organization (HTO) perspective, but lacks a strict taxonomy linked to the understanding of underlying causes of incidents. There is no support to reliably analyses of incident at an overall system or organization level. Inconsistent categorization of incident reports makes effective use of incident reporting systems difficult and evaluation of analyses is adversely affected. A solution could be to expand the IA-system with a text analysis part that can handle free text in the database and search for keywords. By combining free text analysis with taxonomy, trends can be demonstrated from a large amount of data.

【研究緣起與問題】2003年春季，SARS在全球造成一陣轟動，同時也重創全球的經濟，如今SARS會不會再來？政府如何因應？政府如何監測疫情？如何防治疫情？如果SARS等新興及再浮現感染症 （Emerging and Re-emerging Infectious Diseases）出現時，負責全國傳染病防治任務的行政院衛生署疾病管制局是如何作好全國傳染病防治工作呢？中央及地方主管機關之溝通，如何共同消除指責與誤會，發揮團隊精神，如何共同作好全國傳染病防疫任務，爭取公眾對政府之瞭解並加以支持，同時防止任何可能之攻擊，才是全民之福祉。故以「全國傳染病通報系統」的績效，其所仰賴之溝通通路之問題研究，是本研究的動機。了解「傳染病通報管理系統(WEB版)」最大的問題及新興傳染病（如SARS）防治通報的問題及「傳染病通報管理系統」最需要改進之的地方，是本研究的目的。 【研究方法與資料】本研究採取量化與質化並重的方法，以網路問卷方式的進行問卷調查，問卷對象為全國使用傳染病通報管理系統之相關人員，問卷問題內容的設計主要的型式含有開放式問卷（Open –Ended Question）、封閉式問卷（Close-Ended Question）及混合型問卷（Mixed Question）三種。同時以九十二年針對新興傳染病SARS期間為例，深度訪談當時任職於中央與地方負責傳染病防治權責具代表性者五位主管進行訪談，瞭解受訪者對新興傳染病如SARS防治的問題及「傳染病通報管理系統」最需要改進之的地方，以彌補問卷調查法無法深入瞭解到問題之缺點。 【研究結論與建議】 一、根據筆者初步研究經問卷的實證調查之後，從問卷分析資料顯示，使用者使用電腦的時間愈久，對以新版為溝通工具滿意度愈低；而愈瞭解通報系統的使用者，其以新版為溝通工具滿意度愈高，愈滿意新版改進之電腦網路溝通效果。顯示新版的通報系統在設計的操作介面與程序上，沒有人性化，作業內容繁多、需輸入的項目、資料太繁瑣、版面太繁瑣等，反而徒增使用者的困擾；而愈瞭解通報系統的使用者，其對新版的滿意度越高，表示對於使用者在操作上的教育訓練仍須加強，才能發揮新版通報系統的成效。 二、從敘述統計分析中發現： 受訪者對「訊息異動通知作業流程滿意」的使用滿意度的平均數最高，平均數為2.8095表示：較為滿意。「通報作業流程滿意嗎」的使用滿意度的平均數最低，平均數為2.3934，受訪者表示：較為滿意。以新版為溝通工具整體溝通滿意情形，平均數為2.558滿意。 三、開放式問卷分析資料顯示，花太多時間、速度太慢、網路的頻寬過窄又不穩定或無法登錄、作業內容繁多、作業流程問題、資訊管理問題及功能增添與建議等部分。 四、根據筆者初步研究深度訪談之後，彙整中央主管機關及地方主管機關的訪談核心二部分的問題與建議。 五、研究建議： 綜合問卷調查及深度訪談結果，提出政策層面、組織溝通層面、管理層面、實務操作層面等之建議。 【關鍵字】傳染病通報系統、嚴重急性呼吸道症候群(severe acute respiratory syndrome, SARS)、組織溝通、溝通通路、行政院衛生署疾病管制局 / 【Background and Issues】 In the spring of 2003, SARS outbreaks devastated the whole world; they also heavily damaged the world economy. Will SARS come back? How can governments manage it? How can government monitor the epidemics? How can we control the infection? When emerging and re-emerging infectious diseases such as SARS appear, how can the Center for Disease Control of the Department of Health, an organization in charge of national disease control, plan and execute measures for the control of communicable diseases? Effective communication between the central and the local competent authorities to remove together blames and misunderstanding, to develop team spirit, to attain jointly the goal of disease control, to solicit understanding and support of the public to the government, and to prevent any likely attack are some of the considerations in improving the welfare of the public. The reason of the present study was to understand, through the achievements thus far of the National Communicable Disease Reporting System, issues involved in the communication channels. The purposes of the study were to understand the major problems of the Communicable Disease Reporting and Management System (the Web version), issues involved in the reporting of emerging infectious diseases, and areas of the Communicable Disease Reporting and Management System where improvement was most urgently needed. 【Method and Materials】 Both the quantitative and qualitative methods were used. Questionnaire interview was conducted through the web to persons using the Communicable Disease Reporting and Management System throughout the country. The questionnaire contained open-end questions, closed-end questions and questions of mixed types. At the same time, to understand in depth areas not properly covered by the questionnaire interview, five key persons responsible for disease control at the time of the SARS outbreaks in 2003 at the central and the local levels were interviewed to understand their attitudes toward the control of emerging infectious diseases such as SARS, and the improvement most urgently needed for the Communicable Disease Reporting and Management System. 【Results and Recommendations】 1. Preliminary findings from analysis of the questionnaire interview showed that users became less satisfied with the new version communication means the longer they were in use of computers. Users who knew more about the use of the reporting system were more satisfied with the new communication means, were at the same time, more satisfied with the communication effects of the improved version. These facts suggested that the new reporting system was less user-friendly in the designing of interface and procedures. The system required more work, more detailed inputs, and thus added additional burdens on the part of the users. The more the users understood the reporting system, their satisfaction was higher, indicating that, for the new version reporting system to function in full, training of the users in the use of the system should be strengthened. 2. From the descriptive analysis, it was found that the average score of user satisfaction on the “information change reporting procedures” was as high as 2.8095, suggesting that the users were fairly satisfied. The satisfaction score on “reporting procedures” was the lowest at 2.3934. The overall satisfaction score on the use of the new version as a communication means was 2.558. 3. Findings from the open-end questions gave the following recommendations: taking too much time, too slow, frequency of the web too narrow, unstable, and unable to load, too detailed, issues related to operational procedures, issues related to information management and additional functions, etc. 4. By analysis of the in-depth interview, some issues were raised and recommendations made to the central and the local competent authorities. 5. Through questionnaire survey and in-depth interview, some recommendations concerning policies, organizational communication, management and practical operation were made. 【Key Words】 Communicable Disease Reporting System, SARS (Severe Acute Respiratory Syndrome), organizational communication, communication channels, Center for Disease Control, the Department of Health

Sport and dance injuries have increased despite improvements in coaching techniques and medical care. Other factors, including psychological ones, were therefore thought to play a role in injury vulnerability. Most of the attempts to explain how psychological variables can affect an athlete's predisposition to injury have been based on anxiety or stress concepts. In this survey type study an interactive approach to stress has been adopted with the goal of finding a relationship between stress and injury in a group of professional ballet dancers. No simple direct relationship was found. Multiple regression analysis was performed and a more complicated relationship between stress indicators and injury was found. When an attempt was made to investigate the significant interaction, no significant correlations were found. However, the correlations were found to be large and negative. This could indicate that if the sample size had been larger significant correlations may have been found. / Psychology / M.A. (Psychology)

Sport and dance injuries have increased despite improvements in coaching techniques and medical care. Other factors, including psychological ones, were therefore thought to play a role in injury vulnerability. Most of the attempts to explain how psychological variables can affect an athlete's predisposition to injury have been based on anxiety or stress concepts. In this survey type study an interactive approach to stress has been adopted with the goal of finding a relationship between stress and injury in a group of professional ballet dancers. No simple direct relationship was found. Multiple regression analysis was performed and a more complicated relationship between stress indicators and injury was found. When an attempt was made to investigate the significant interaction, no significant correlations were found. However, the correlations were found to be large and negative. This could indicate that if the sample size had been larger significant correlations may have been found. / Psychology / M.A. (Psychology)