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Two findings in this study were unanticipated. During the 16 study observations, 27 pharmacy deliveries were made to the medication areas. Likewise, several conversations about medication preparation occurred between a nurse preceptor and an orientee. Neither of these findings was included as an interruption because it was not clear whether a true interruption had occurred.

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Medication errors are a significant cause of morbidity and mortality in hospitalized patients. 26 In ICUs where medications comprise a significant proportion of a patient’s treatment regimen and where medication preparation and administration are primarily nursing functions, evidence-based interventions are needed.

The NIZ is a way to implement the policies associated with the sterile cockpit into the health care setting. In an ICU environment, where patient care is complex and uncertain, distractions and interruptions during medication preparation can affect medication safety by creating errors in any 1 of the 5 “rights” of medication administration (the right medication, the right dose, the right time, the right patient, and the right route). From China Free Shipping Low Price Discount Classic Stella McCartney BuckleAccented Wool Coat Outlet Perfect Huge Surprise Cheap Online Buy Cheap For Sale YyYnKMS
This pilot study is the first to report on the effectiveness of the NIZ in critical care. After a 3-week period, a significant decrease (40.9%) in interruptions had occurred. These results, although preliminary, suggest a beneficial effect of an NIZ on decreasing interruptions during the critical task of medication preparation. Whether this decrease in interruptions is sustainable over time needs further investigation.

Other Findings

Although the responsibility for medication preparation and administration resides primarily with nurses, physicians and respiratory therapists were observed in several instances to be retrieving medications inside the NIZ (8 by respiratory therapists and 1 by a physician). This is an example of the complex systems in which medication administration is embedded. It is presumed that quality health care is best delivered within a team approach. Caution is warranted, however, in that without communication and coordination, the team approach may also contribute to error-prone conditions. Thus, including all health care professionals in any comprehensive education for any medication safety initiative enhances its chance for success.

Another incidental finding from this study involved a situation that may affect medication safety that has not been described before. When a nurse is new to an ICU, for a while, he or she discusses and validates medications with a preceptor before administering them to the patient. These discussions usually occur in the middle of the NIZ. During data collection, conversations between a preceptor and an orientee about medication preparation occurred twice but were not counted as interruptions. Similar to the airline industry, where only relevant conversation occurs when flying at less than 10 000 feet, the purpose of the NIZ is to eliminate conversation and activities unrelated to medications. Yet it remains unclear how necessary, medication-related conversations should occur safely in the NIZ. Further, when more than 1 nurse is in the NIZ, a necessary conversation for one nurse may be a distraction for another nurse. Practices such as these that have unclear contexts need further examination.

Pharmacists have a significant role in the prevention of medication errors. Ruffled sleeves dress Patrizia Pepe Sunshine kJBfNKLD
Interestingly, system factors that involve the role of the pharmacy in the act of dispensing medications may in fact be a contributing factor to medication errors. In the setting in which this study took place, the pharmacy delivers medications to the ICU every hour from 6 am to 10 pm and then every 2 hours from 10 pm until 6 am . During data collection, the data collector noted that pharmacy personnel waiting to refill patient medication bins did not actively interrupt the nurse preparing medications. However, they were most likely noticed in the background, and could be a factor in the nurse’s losing concentration, feeling rushed or otherwise distracted. In the current pilot study, the potential interruption was unexpected, unaccounted for in the design, and therefore not counted as an interruption.

During the debriefing, enthusiastic comments regarding the usefulness of the NIZ and ideas for reconfiguration of the NIZ were made. Nurses’ positive anecdotal reports supported their increased awareness of medication safety and the need to remain focused while preparing medications. Several nurse practitioners and nurse managers also made comments such as, “I used to go right up to someone at the medication cart; now I wait until they are finished and leave the box [NIZ] before I approach them.” A surgeon commented on the importance of the project and recommended the use of an NIZ during induction of anesthesia in the operating room.

NIZ Layout

Several issues came up that require further consideration in a larger study than this pilot study. Red duct tape was used to create the NIZ. It was chosen because it was “attention getting” and inexpensive but was not labor intensive to implement. Duct tape, however, may not be the ideal tool for maintaining the NIZ. Over time, the red tape became worn and lost its striking clean physical appearance. Additionally, the NIZ “moves” when the medication carts are moved. In future studies, the use of a red mat, a red flashing light, or other signage may be more suitable for preserving the functional and aesthetic appearance of the NIZ.

Patterns of medication administration must be assessed before the boundaries of the NIZ are determined. In this pilot study, the zone included an area around the medication counters but did not stretch far enough to include the medication refrigerator. Including all medication-related workspace would have allowed a more comprehensive picture of occurrences and interruptions related to all routes of medications.

NIZ Practice Change

Despite the dramatic change in interruptions after the NIZ was implemented, when a new practice is introduced, ongoing education with reinforcement is one way to “cement” the practice. The study findings shed some light on the need to include not only nurses but all persons who have a role in medication safety within a complex system. In changing practice, time is also needed for staff engagement. Although consistency in a NIZ protocol is essential for widespread recognition, the culture of an individual unit may have to be considered during implementation to enhance the chances of success of an NIZ. Each nurse must take personal accountability for preserving the NIZ as a place for focus during the critical task of medication preparation; in doing so, each nurse will be part of the force that transforms nursing practice and improves patients’ safety.

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This study was conducted in 2 ICUs and therefore the findings may not be generalizable to other ICUs or general medical-surgical units. This was a pilot study and observation sessions and hours were limited to 1 week of data collection both before and after NIZ implementation and by the availability of the data collector. The nature of observational research lends itself to additional limitations. The data collector did not know what the nurse was thinking or if he/she was distracted or interrupted with thoughts other than medication preparation. A follow-up interview could clarify the nature and scope of self-interruptions. We were unable to control for certain types of interruptions such as overhead pages, pharmacy deliveries, and alarms.

(Albania - April 12, 2018) The Apollonia Archeological Park, in southwestern Albania is on the tentative list of UNESCO World Heritage sites. This ancient city flourished in the 4th century AD as an important economic and trade center. The ruins were discovered in the beginning of the 19th century.

Grant For Tourism

It’s this sort of initiative that underscores the 40 million euro joint grant to Albania from the EU and the European Bank for Reconstruction and Development (EBRD) for the purpose of developing the country’s tourism industry and creating thousands of jobs to boot. In addition to the restaurant/agritourism scene, there is a lot in Albania with which to work. The country’s landscape and traditions are home to thousands of years of human history and civilization: Greek and Roman cities and temples from the pre-Christian era when Albania was an important naval and trading outpost; Roman Catholic and Orthodox churches, Turkish mosques. In modern times, Mussolini’s 1939 invasion actually left the country with several decent buildings and strong cultural and financial ties to Italy (Italian is practically the country’s second language). Following the Hoxa Communist era, proselytizing evangelicals introduced other Protestant faiths. The result is a level of egalitarianism unusual for the Balkans.

But there’s a long way to go. While Albania may have a Mediterranean climate, 296 miles of coastline along the Adriatic and Ionian seas, acres of mountains and three UNESCO historic sites, it is sorely lacking in some key tourism essentials: the number and caliber of hotel rooms, safety handrails along ancient steps and pathways, clean beaches and trash-free countryside, efficient transportation and access. That’s all on Rama's to-do list.

Tourists from neighboring Italy already have access by ferry from Brindisi and Lecce, and soon there will be more direct flights from Europe. “We are launching our own airline company, Air Albania, this summer,” Rama confirms. "We’ll expand our existing flights with Italy, Germany and the UK and the neighboring Balkan states, and we are building an airport in Vlora, in the south near Greece, where the best beaches are.” The airport, a private-public partnership, is being partially financed by Turkey's Cengiz Construction company.

(Berat, Albania - April 11, 2018) Byzantine iconography at an Orthodox altar in Berat castle, a UNESCO World Heritage site, dating from 600 BC. The castle houses both churches and mosques.

Albania is already somewhat of a destination for the budget or adventure-loving traveler (nearly four million people visited Albania in 2016 according to international tourism statistics), but Rama has his sights on the five-star market. Four Seasons and Marriott are said to be looking at properties and sites in the capital. “We want to be the kind of destination Italy was some years ago,” Rama says. “Small, with a lot of beauty and positive energy.”

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Journal Article
JAMES E. HOLLOWAY, JR.
Vol. 5, No. 1 (Otoño 1980), pp. 37-59
Published by: Kite Woolblend Skirt Black Vivienne Westwood Cost For Sale Finishline Cheap Price 7FYhzs
Stable URL: https://www.jstor.org/stable/27762074
Page Count: 23

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Revista Canadiense de Estudios Hispánicos
Description:

was founded in 1976 and is the official publication of the Canadian Association of Hispanists. The mandate of the journal since its inception has been to become an international forum in Canada for the exchange of scholarship and intellectual inquiry in Hispanic Studies along a broad spectrum of methods and approaches. By publishing cutting-edge, high-quality, thought-provoking work by outstanding Canadian and international scholars, the journal serves to connect Canadian scholarship in Hispanic Studies and the international community. We aim to continue being a forum of excellence for researchers in the field of Hispanic Studies-culture, literature, and film‚ and we note that is presently considered one of the leading journals in our discipline.

Coverage: 1976-2016 (Vol. 1, No. 1 - Vol. 41, No. 1)
Moving Wall:

The "moving wall" represents the time period between the last issue available in JSTOR and the most recently published issue of a journal. Moving walls are generally represented in years. In rare instances, a publisher has elected to have a "zero" moving wall, so their current issues are available in JSTOR shortly after publication. Note: In calculating the moving wall, the current year is not counted. For example, if the current year is 2008 and a journal has a 5 year moving wall, articles from the year 2002 are available.

Terms Related to the Moving Wall Fixed walls: Absorbed:

Between the two ends of the spectrum lie many close cases, in which the courts will apply the factors listed above. So, for example, where the marks are similar and the products are also similar, it will be difficult to determine whether consumer confusion is likely. In one case, the owners of the mark "Slickcraft" used the mark in connection with the sale of boats used for general family recreation. They brought an infringement action against a company that used the mark "Sleekcraft" in connection with the sale of high-speed performance boats. Because the two types of boats served substantially different markets, the court concluded that the products were related but not identical. However, after examining many of the factors listed above, the court concluded that the use of Sleekcraft was likely to cause confusion among consumers. AMF Inc. v. Sleekcraft Boats, 599 F.2d 341 (9th Cir. 1979) .

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In addition to bringing an action for infringement, owners of trademarks can also bring an action for trademark dilution under either federal or state law. Under federal law, a dilution claim can be brought only if the mark is "famous." In deciding whether a mark is famous, the courts will look to the following factors: (1) the degree of inherent or acquired distinctiveness; (2) the duration and extent of use; (3) the amount of advertising and publicity; (4) the geographic extent of the market; (5) the channels of trade; (6) the degree of recognition in trading areas; (7) any use of similar marks by third parties; (8) whether the mark is registered. Cheap Visa Payment Cheap For Cheap Martin Grant SemiSheer Sleeveless Dress Best Deals Free Shipping Fake R3QIkf2wUI
. Kodak, Exxon, and Xerox are all examples of famous marks. Under state law, a mark need not be famous in order to give rise to a dilution claim. Instead, dilution is available if: (1) the mark has "selling power" or, in other words, a distinctive quality; and (2) the two marks are substantially similar. Mead Data Central, Inc. v. Toyota Motor Sales, U.S.A., Inc., 875 F.2d 1026 (2d Cir. 1989) .

Once the prerequisites for a dilution claim are satisfied, the owner of a mark can bring an action against any use of that mark that dilutes the distinctive quality of that mark, either through "blurring" or "tarnishment" of that mark; unlike an infringement claim, likelihood of confusion is not necessary. Blurring occurs when the power of the mark is weakened through its identification with dissimilar goods. For example, Kodak brand bicycles or Xerox brand cigarettes. Although neither example is likely to cause confusion among consumers, each dilutes the distinctive quality of the mark. Tarnishment occurs when the mark is cast in an unflattering light, typically through its association with inferior or unseemly products or services. So, for example, in a recent case, ToysRUs successfully brought a tarnishment claim against adultsrus.com, a pornographic web-site. Toys "R" Us v. Akkaoui, 40 U.S.P.Q.2d (BNA) 1836 (N.D. Cal. Oct. 29, 1996) .

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