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LOT-986 exam Dumps Source : Creating IBM Lotus Notes and Domino 8.5(R) Applications with Xpages and Advanced Techniques
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Test cognomen : Creating IBM Lotus Notes and Domino 8.5(R) Applications with Xpages and Advanced Techniques
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IBM Creating IBM Lotus Notes
When IBM purchased Lotus for $three.5 billion in 1995, it seemed as even though the venerable computing colossal was just about to lock up the application trade and coast to unstoppable gains.
Eighteen years later, Lotus appears extra love a millstone round IBM’s neck than a flywheel giving it added speed.
in accordance with a file within the Wall street Journal, in extend of IBM’s this Fall revenue release nowadays, Lotus was the weakest performer in IBM’s software portfolio, shedding 6.four p.c of its sales quantity within the first 9 months of 2012.
It doubtless accounts for about $1 billion in annual profits, in keeping with estimates sourced by the WSJ, or one-sixth to 1-fifth of IBM’s typical software company.
ironically, Lotus as soon as led the style towards today’s most well-liked commercial enterprise applied sciences, the collaborative application that helps groups communicate and drudgery collectively on projects. some of the success reports of that area of interest is Yammer, which Microsoft got final year for $1.2 billion. So, why is IBM sitting at the back of the pack as an alternative of leading from the front?
Lotus, which made the first blockbuster “killer app” within the Nineteen Eighties (Lotus 1-2-three, a phenomenally a hit spreadsheet program), went on to create Lotus Notes, a powerful groupware suite that came out within the early Nineties earlier than any one had any theory what “groupware” turned into.
I used it radically at a number of businesses I worked with. firstly, it became inscrutable and robust. love most conclusion-users of Lotus Notes, I used it basically as an e mail program. It had its quirks, nonetheless it worked. however there became an extra dimension to Notes, a powerful, programmable backend that permit you to create databases and workspaces for collaborative work, contact management, recommendation sharing, and verbal exchange.
these days, we’d muster it a collaboration device or a company social-media tool, and it could subsist net-based and requisites-compliant, love Yammer, Jive, and Huddle. within the absence of requirements, Notes’ engineers had to invent everything themselves, making it a artful but proprietary solution.
however long earlier than those net-based mostly startups got here along, Notes turned into already dropping its cool. The customer software grew to become massive and bloated. It became expensive to implement and elaborate to personalize.
as the information superhighway won recognition in the late Nineteen Nineties, Lotus added specifications, love POP3 and IMAP email interfaces. They didn’t achieve so well with the requisites branch, youngsters, using any individual who needed to exhaust an online mail client with a Lotus Notes mail server fully insane.
The upshot is that, simply as the cyber web grew to subsist commonly used, Lotus Notes grew to subsist stressful and out of date.
certain, it changed into nevertheless powerful, but unlocking the vitality of Notes regularly required professional expertise, giving upward push to a sector of Notes consultants. No shock that these consultants are having a tough time getting taken critically today. The WSJ rates a Notes consultant who complains about his reception:
“i proceed to a celebration, and i shortly net insulted,” says Eugen Tarnow, a director of the consultancy Avalon traffic techniques, which sells the growing older e mail software to organizations. “they are saying, ‘Lotus Notes, that’s nevertheless around?’ It’s no fun.”
lamentably, IBM’s engineers realized the magnitude of requisites compliance too late and didn’t bake interoperability into Lotus Notes smartly enough or early satisfactory. So, as powerful as Notes could be, it was and is ill-organized to drudgery in today’s API-rich cloud atmosphere.
IBM has greater up to date social-media utility, too, but best makes about $fifty five million per yr from that segment of its company. So the challenge for IBM is to proceed milking as tons revenue as it can from Lotus, while gradually transferring the branding and the revenue to more moderen, sexier traces of business. One illustration: Renaming its annual Lotus conference, Lotusphere, as “Connect2013.” Yeah, that’ll assist.
We’ll subsist gazing to spy if the income record sheds any longer mild on IBM’s efforts to exhibit Notes around. but as for me, I’m now not holding my breath.
photograph credit: Andrew Mason by course of photopin cc
IBM Modernizes Domino enterprise App Platform
by using David Ramel
IBM has modernized Domino, its company app platform with roots within the Lotus Notes ecosystem that debuted in 1989.
as soon as essentially conventional because the server-aspect side of Lotus Notes, Domino is a multi-faceted platform that offers app building -- the usage of the speedy-utility-construction strategy -- and greater.
In revamping the 29-12 months-old platform, IBM has better cloud assist, cell utility building, analytics and boosted the collaboration capabilities that had been a mainstay of Lotus Notes, which grew to become IBM Notes in a 1995 acquisition.
Two of the most high-quality modernizations within the original IBM Domino v10 are cell app construction capabilities and the embrace of node.js.
The stronger cell development performance comes in the original IBM Domino mobile Apps, which is being previewed as a beta for which developers can register. Furthering the IBM/Apple company relationship, the offering lets developers create Apple iPad company apps. "IBM Domino additionally replicates statistics between the server and local version of your functions, so your group will moreover subsist productive even without network connectivity," the traffic said.
yet another original characteristic is the potential for developers to cognomen any ease APIs from Domino applications, enabling the capability, for examples, so as to add Google Maps performance, pull in Salesforce consumer records or leverage IBM's Watson capabilities.
the brand original Domino v10 stems from a building settlement IBM entered into with HCL applied sciences a year in the past.
David Ramel is the editor of visual Studio magazine.
the course to create an simple Todo app the exhaust of
IBM Notes, with IBM ODBC Driver
developing the Todos view and Todo form
Create an todos.nsf database in Notes with a view with the alias identify todos, and a kind referred to as Todo.The todos view, should quiet maintain a column known as unid, todoText and todoComplete. The unid column indicates the files universialID.
Create a kind with the fields, todoText and todoComplete.
Then create a original Todo doc with some information.
Configuring the ODBC driver
You’ll want the IBM ODBC Driver for Notes/Domino. that you can net it from http://www.ibm.com/developerworks/lotus/toolkits.html
if you requisite to exhaust the motive compel with the Notes client, you’ll should exhaust the 32bit edition.
down load and install the driver, then beginning up the windows ODBC manager.
Add a brand original Lotus Notes SQL Driver (*.nsf)
Config the driving force, exhaust endemic for server, and todos.nsf for database.
I did add my consumer.identification file and my password to the driver, then I don’t maintain to retain in that assistance when connecting to the database later.
Go to the Connection Pooling tab(in ODBC supervisor), I delivered 600 sec. for the Lotus Notes SQL Driver.
installing odbc driver for node
For connection to the odbc in node I’m the usage of the node-odbc driver. The node-odbc driver requires node-gyp, in case you maintain inconvenience installing it, read the deploy instructions over at https://github.com/nodejs/node-gyp
npm deploy odbc
look at various the connection
Create a file known as app.js
if your connection is adequate, it'll print one row with the doc they created past.
The Todo Expess app
the required dependencies, are:
Create the endpoints for the leisure API.
The comprehensive app.js should spy love this
Now their leisure api is achieved.
There are a lot of tutorials on the course to create an angular Todo apps. instead of repeating that suggestions perquisite here, that you would subsist able to download the finished Todo app with with both the express app and the Angular entrance-conclusion from https://github.com/nthjelme/notesnodetodo
after you maintain downloaded the code, open a console, cd to the folder you downloaded the code, and sort:
npm installnpm delivery
Open http://localhost:3000 to your browser, and moreover you should subsist able to note the Todo app running! (in case you created the view,form the odbc connection the equal approach as above.)
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I must admit, it’s been awhile since I covered or thought about IBM or Lotus Notes/Domino, but this announcement struck me as particularly interesting.
In case you missed it, IBM has completely dropped the Lotus moniker. Its next release is IBM Notes/Domino 9.0 companionable Edition; the original name really rolls off the tongue doesn’t it? Well there’s a reason IBM has gone this route.
The IBM cognomen is more widely recognized and the company was readying the Lotus Notes/Domino 8.5.4 with companionable Edition features. Now it has rolled everything up into one completely original client/server release (though the focus is moreso on the client-side).
Note: A Notes/Domino 8.5.4 update is quiet planned.
This led me to touch groundwork with a past contact (who wished to remain anonymous).
“I contemplate it’s about time they dropped the name,” he said. “Holding onto the Lotus brand was going to maintain more of a negative repercussion than a positive one.”
He suggested that the Lotus cognomen is associated with a legacy platform — whether rightly or wrongly. By tweaking the name, Notes/Domino companionable Edition is now a “new” idea.
Social Edition allows Notes apps to sprint in a Web browser. Additionally, there are email and calendar enhancements and Xpages improvements, just to cognomen a few.
While IBM’ers tout returning customers, it remains to subsist seen how efficient the original naming convention and features will prove.
The Notes/Domino 9.0 companionable Edition beta will subsist available for download a month from today — December 14 — and the official release is expected Q1 2013. This brings up an bright point.
Exchange Server 2013 is moreover slated to release Q1 2013. Is this a coincidence? Yes, it probably is; IBM has been working on these products for a while and the shift has added a bit more drudgery into the process.
Any thoughts on the announcement? Feel free to email me.
This is not a typical DKos post (at least, not for me), but this thread over at Kevin Drum's region got me thinking about a very simple question: achieve you love your job?
The title of this post, of course, refers to the 80s anthem by Loverboy of (more or less) the very name. But how apt is that saying? I'm really curious to know how people feel about their current employment. If you love your job, why? If not, why not? And are you planning to achieve anything about it? achieve you contemplate you'll ever find a job you truly love? And for those of you who already achieve esteem their jobs, how did you wind up with your job, and why exactly achieve you esteem it? Hmm... perhaps it's not such a simple question after all!
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Update [2005-7-8 23:0:56 by DavidNYC]: This has been a truly fascinating thread - I inspirit you to read complete the course through it. There are comments from an extraordinary array of people: A bodybuilder, a tattoo artist, and a horse breeder to cognomen a few of the more unusual jobs.
But just as importantly, this thread has reminded me of what I esteem most about Daily Kos: The diversity of backgrounds combined with a universal desire to learn and listen. I contemplate the site is at its best when these traits are showcased, as they are in this thread tonight.
Effective communication is central to patient safety and quality. Inadequate communication consistently appears as a factor contributing to medical errors, across settings and practitioners. These span from an incident with a separate patient1 to broader communication issues between physicians and nurses.2 In reviews of malpractice claims, communication problems were contributing factors in 26% to 31% of cases.3–5 The Joint Commission has reviewed data from 6,244 sentinel events occurring between 1995 and June 30, 2009.6 Communication problems maintain long been renowned as a major contributing factor to these sentinel events. Sutcliffe et al7 conducted semistructured interviews with residents, who recalled 70 recent medical mishaps, and indicated that 91% contained communication failures.
Handoffs, the transfer of patient saturate from one health saturate provider to another, are known to subsist vulnerable to communication failures8 and maintain been called “remarkably haphazard.”9 As defined by the Joint Commission, handoff communication refers to a standardized process “in which information about patient/client/resident saturate is communicated in a consistent manner.”10
Retrospective reviews of malpractice claims in the ambulatory setting11 and emergency department12 showed that handoffs were a contributing factor in 20% and 24% of medical errors, respectively. When looking specifically at malpractice cases with communication breakdowns, 43% involved handoffs.13 A review of 146 surgical errors institute that 41 (28%) involved handoffs.14 Of residents and fellows who reported caring for a patient with an adverse event, 15% indicated the intuition for the mistake was a problem with handoffs.15
Numerous surveys document health saturate staff concern. In an Agency for Healthcare Research and property 2008 survey, just over half (51%) of the 160,176 hospital staff respondents reported that “important patient saturate information is often lost during shift changes.”16 When 93 fourth-year medical students and 228 residents responded to a survey about patient safety, (70%) agreed that improved handoffs would reduce medical mishaps.17
Reduced resident duty hours were first introduced in original York status in 1989 and were mandated for complete U.S. residency programs in 2003. Although reductions in duty hours may lead to less fatigue and improved well-being in residents, many maintain expressed concern about the resultant requisite for increased handoffs and reduced continuity of patient care.18 As a result of reduced hours, patients can subsist seen by three different physicians in the first 24 hours of their care.19 Seventy-six percent of 29 surgical residents in a original York study agreed that continuity of saturate had been negatively affected as a result of duty hours changes.20
Discontinuity in patient care, which can occur with cross-coverage and night float systems, has been institute to lead to increased in-hospital complications,21 preventable adverse events,22 increased cost due to unnecessary tests being ordered by residents not intimate with the patient,19 and diagnostic test delays.21 In a study at one teaching hospital during a four-month period, the risk of a preventable adverse event was strongly associated (more than twice as likely) with coverage by a physician from another team.22
Night float systems, often implemented to ensure that residents achieve not exceed duty hours limits, maintain been renowned to result in inadequate information transfer to the covering residents.23 Nurses maintain expressed concern over these changes. Fifty-one percent of the 67 nurses who responded to a survey about a original resident night float system agreed that “residents don’t know the patients as well as in the former system.”24
Other issues surrounding attending physicians’ and residents’ handoffs maintain been documented. Gandhi25 notes that inadequate handoffs can lead to diffused responsibility, which can subsist a major contributor to medical errors. In addition, Coiera26 institute that health saturate communications are recumbent to interruptions, with a third of communication events (30.6%) interrupted.27 Many of these interruptions result in inefficiencies,28 and interruptions during handoffs are likely to lead to failures of working memory,29 which result in decreased recall accuracy.
In 2006, the tolerable length of tarry for complete hospitalized patients was 4.8 days.30 Assuming that patient saturate transfers between covering residents and/or attending physicians occur 1 to 2 times per day, the tolerable patient will subsist handed off 5 to 10 times per admission. Each of these handoffs represents a risk for inadequate communication, which could result in reduced patient safety and increased medical errors.
In response to concerns about inadequate health saturate handoffs, a number of national patient safety organizations maintain highlighted the weight of communication, including the Institute for Healthcare Communication31 and the National property Forum. In 2006, the Joint Commission created a original National Patient Safety Goal on handoffs.32 In 2009, the goal remains virtually unchanged, requiring the organization to implement “a standardized approach to hand-off communications, including an break to examine and respond to questions.”33
As the preceding paragraphs suggest, there is abundant evidence of the negative consequences of impoverished communication and inadequate handoffs in health care. The purpose of the current study was to identify complete English-language articles on resident and/or attending physicians’ handoffs in the United States, conduct a systematic review of research studies, achieve a qualitative review of barriers and strategies mentioned across complete articles, and identify features of structured handoffs that maintain been shown to subsist effective. This review was conducted in conjunction with the Alliance of Independent Academic Medical Centers National Initiative: Improving Patient saturate Through GME. The National Initiative was a collaborative formed in 2007 that linked residency programs in 19 teaching hospitals across the United States in efforts to integrate academics and property through projects coordinated at a national level.
National initiative drudgery group
A drudgery group of the National Initiative developed resources and wrote systematic reviews of the literature in advocate of the National Initiative's goals. They performed this study as one of a chain of literature reviews initiated by that group. The methodology that they employed included regular, substantive discussions about manuscript concept and design, such as key questions, inclusion and exclusion criteria, and search strategies. There were critical interchanges among us about complete well-known aspects of each systematic review written by this group, including those for this report, and they reached consensus on how to treat each systematic review. The specific subject, appropriate technique, and final presentation of this systematic review are the product of a progressive, iterative, and qualitative process of refinement.
We conducted a thorough and systematic literature search of English-language articles published on handoffs from 1987 to June 4, 2008 using Ovid Medline, Medline In-Process & Other Non-Indexed Citations, CINAHL, HealthSTAR, and Christiana saturate complete Text Journals@Ovid, followed by reference section review. The search terms used were hand-off$, handoff$, signout$, token out$, sign-out$, handover$, hand-over$, signover$, and sign-over$. A total of 2,590 articles were identified. complete titles were reviewed for feasible inclusion, and 401 articles were obtained for further review (Figure 1). Reference sections of complete 401 articles were reviewed for additional articles.
Articles meeting the following criteria were eligible for review of barriers and strategies: English language, indexed in PubMed, published between 1987 and June 4, 2008, focused on health saturate handoffs in the United States, and including information about either resident or attending physicians’ handoffs. Articles included in the systematic review had one of the following study designs: randomized controlled trial; nonrandomized trial, with control or comparison group; single-group pre- and posttest, cohort study; single-group cross-sectional research; single-group posttest only, or qualitative research.
Trained reviewers (J.L. and L.R.) deemed that 46 articles met inclusion criteria for the initial review of barriers and strategies. Using an iterative process, an abstraction configuration was developed to verify eligibility for complete review, assess article characteristics, and extract data material to the study questions. This iterative process started with an initial form, which was used by two reviewers (J.L. and L.R.) to independently abstract data from four articles. The reviewers then met to argue the abstraction configuration for inclusion of complete material data. A second, more detailed configuration was then created for abstraction. Reviewers (J.L. and J.M.) independently absorbed complete data. Most abstraction disagreements were minor, and complete disagreements were quickly resolved during discussion, when a consensus was reached on the absorbed data.
Quality scoring system
Downs and Black34 created a sound and dependable checklist designed to assess both experimental and observational studies. Two systematic reviews35,36 of published systems (scales and checklists) designed to assess study property maintain ranked the scale developed by Downs and Black as one of the best. Both of these systematic reviews went on to hint that some modifications might subsist useful, depending on the specific topic and study designs. Therefore, five of us (L.R., J.L., J.M., J.J., J.S.P.) developed a property scoring configuration based on this approach, using four of the original items and eight modified items, which yielded scores ranging from 1 to 16, with 16 being the highest feasible score (see Chart 1). This property scoring configuration contained two items related to study ilk and sample size, five items related to reporting, and five items related to internal validity.
If a study included multiple assessment formats, such as interviews and a questionnaire, that resulted in different sample sizes, the largest sample was used as the sample size in the property scoring form. There was no course to determine the number of independent study participants for each assessment method. Thus, to avoid counting the very study participant multiple times, they credited the study with the largest reported sample only.
Quality scores were independently obtained from reviewer pairs (L.R. and J.L. or J.J.) for each study. The interrater reliability was assessed for complete identified research studies (n = 18). Overall agreement was 97.7%, and Cohen's kappa for agreement between the two reviewers was r = 0.96, P < .001. complete differences were resolved through discussion to defer a final property score for each study.
Qualitative analysis of barriers and strategies
Conventional content analysis is a ilk of qualitative research used when there is limited or no existing theory on the phenomenon of interest.37 This analysis involves an iterative process that allows themes to arise from data. Researchers immerse themselves in the content and allow categories to emerge.37
All barriers and strategies mentioned in the reviewed articles were identified and listed in phrase format in two continuous lists, one for strategies and another for barriers. Reviewers (J.L. and L.R.) met to compare lists and, through discussion, agreed on final comprehensive lists. Through an inductive iterative process, category labels were created and complete phrases were moved to a category or subcategory. The final lists were reviewed by J.M. for coherence and consistency.
Forty-six articles describing resident and/or attending physicians’ handoffs were identified. Thirty-three (71.7%) were published between 2005 and 2008 (Figure 2). Content analysis yielded 91 barriers in eight major categories and 140 strategies in seven major categories (Table 1).
Twenty-two articles presented anecdotal data,38–58 one of which had a physician handoffs case case and nursing handoffs research59; three provided circumscribed reviews,60–62 and three were editorials.63–65 The remaining 18 articles reported research on handoffs and were analyzed in depth (see the Appendix).66–83 Only one80 research study did not involve residents or maintain a graduate medical education focus. property assessment scores for the research studies ranged from 1 to 13 (possible sweep 1–16). Six studies obtained scores of 8 or less, eight had scores between 8.5 and 11.5, and four achieved property scores of 12 to 13.
Only 6 of 18 (33.3%) research studies identified efficient handoff features.66,67,69,71,77,78 In studies comparing computerized handoff systems with other methods, such as personal handwritten notes, the computerized or electronic system performed better. Residents were more likely to maintain complete patients on their list,67 to report that they received complete well-known information,78 to maintain increased satisfaction with the handoff system,67 to spend less time in prerounding and rounding activities,67 and to self-report decreased adverse events related to handoffs.77 Others maintain renowned that resident-maintained lists in a database, such as a Microsoft Word file or outstrip database, contain content and medication errors.69,71 However, interns using standardized, self-maintained sign-out cards reported fewer impoverished sign-outs and were more likely to record code status, patient age, and allergies.66
As stated earlier, they identified 46 articles describing residents’ and attending physicians’ handoffs in the United States. Eighteen were research studies (39.1%), only two of which were randomized controlled trials. The majority (71.7%) of articles were published in recent years, which is not surprising, given the Joint Commission's National Patient Safety Goal on handoffs issued in 2006. However, as demonstrated by their property assessment scores (see the Appendix), there is a remarkable lack of high-quality outcomes studies. It is notable that one third of the reviewed research studies obtained property scores at or below 8 (out of a feasible 16), and only one study achieved a score of 13.
One purpose of the current study was to identify features of physicians’ handoffs that maintain been shown to subsist effective. Unfortunately, only 6 of the 18 (33.3%) research studies included measures of effectiveness. Of the three studies using computerized handoff systems, one was a stand-alone system,78 and the other two had some linkage with the hospital computer system.67,77 While these complete provided a structured template, they moreover relied to varying degrees on residents to enter information, which introduces an break for errors to occur.69,71 Most of the studies assessing effectiveness used self-reported data, with a few exceptions. Van Eaton and colleagues67 looked at the number of patients missed on resident rounds and showed a diminish from 5 to 2.5 patients/team/month (P = .0001) when using a computerized handoff system. Two other studies assessed errors on resident-maintained handoff forms when compared with the medical record69,71 (a surrogate for actual medical errors) and, not surprisingly, institute errors on the resident lists.
Of note, two survey studies documented a lack of formal handoffs instruction during residency, with 60% to 74.4% (internal medicine72 and emergency medicine,73 respectively) reporting that they maintain no lectures or workshops on the topic. Although 72.3% of the 185 emergency medicine residency/fellowship program directors studied agreed that standardized handoffs would reduce medical errors,73 the majority did not maintain a uniform policy or procedure regarding handoffs. Only one of the studies reviewed here included the development, implementation, and assessment of a formal, structured handoffs curriculum.75 Horwitz and colleagues75 provide a comprehensive curricular template for others to use; however, they relied on postsession evaluations of perceived console and weight of handoffs. They commend their arrangement to conduct observation of handoff skills and spy forward to their future publications.
Almost complete of the research articles (17 of 18; 94%) were conducted within a residency program. Graduate medical education has taken the lead in conducting handoffs research, which is one demonstration of the value added to health saturate by medical education.
We identified 91 barriers to efficient handoffs that could subsist organized into eight major categories. Of barrier categories, communication issues were reported most frequently (30.8%), with generic communication barriers ranging from not listening to inadequate communication. Because efficient communication is an essential component of handoffs, this was an expected finding. However, hierarchy and companionable barriers constituted a less intuitive group. Here, they institute things such as relational communication barriers and residents not being likely to hand off drudgery to more senior residents, because of a rigid reliance on hierarchical norms that prohibit such behavior. Thus, adequately addressing handoff issues will require more than protocols, structure, and training. Understanding the complex companionable structures and hierarchies in which residents and attending physicians work, as well as the unwritten rules that govern the handoff of patient responsibilities, will subsist required.
We identified 140 strategies that could subsist organized into seven major categories. Strategies for standardization were renowned most frequently (44.3%), with technological solutions (16.4%), such as computerized handoff systems, next. Interestingly, whereas communication issues constituted approximately one third of barriers, improving communication skills was renowned much less frequently (11.4%) as a strategy. Standardization would address some communication issues, but not all, such as language differences. Providing training or education (10%), evaluating the process (7.1%), and addressing environmental issues (5.7%), such as lighting and limiting interruptions and noise, do intuitive sense. However, a less obvious strategy was insuring the recognition that a transfer of responsibility/accountability (5.0%) had occurred.
Limitations and strengths
Handoffs in a variety of environments were studied, which makes it difficult to exhaust their findings to formulate barriers and strategies for exhaust in every handoff situation. For example, some techniques may subsist better applied to inpatient medicine as opposed to the emergency department. In addition, they absorbed barriers and strategies from complete sections of the articles studied, including the introduction. This may maintain resulted in overemphasis of some barriers or strategies, depending on the author's views and on repetition. However, they only counted the very barrier or strategy multiple times if the wording was significantly different in subsequent exhaust and if the two instances could stand lonely as different aspects of the very category.
Another potential limitation is that the barriers and strategies they identified (Table 1) represent the opinions of the authors of the reviewed studies. Further, they identified the barriers and strategies through a qualitative process. Although they appear intuitively relevant, they were not derived from research studies designed to identify handoff barriers and strategies.
The current study is limited by the Ovid search strategy used. Specifically, the selected search terms may not maintain included complete material terms. They strengthened the possibility of identifying complete articles that met inclusion criteria by reviewing the reference sections of complete obtained articles. Although this strategy minimizes the risk of missing germane studies, it does not eradicate the possibility.
Publication jaundice refers to the possibility that high-quality studies with negative results may not maintain been published. Others maintain renowned that many property improvement (QI) projects are not published.84 In addition, it has been their observation that some QI projects are published in newsletters, with the authors never submitting them to peer-reviewed journals. Thus, there may subsist outcomes studies of handoffs that are not in the peer-reviewed literature. However, the express search strategy, clear inclusion criteria, and systematic process used to identify and evaluate articles strengthen the property of this review.
Although their property scoring system was based on a validated methodology developed to assess experimental and observational studies together, their system has not been validated across multiple settings and investigators. The relative weightings may require refinement, and there may prove to subsist additional material categories. The system did maintain a towering internal reliability, and reviewers of various educational backgrounds and taste institute it straightforward and simple to use. Further, the property scoring system provides a reproducible template for the assessment of handoffs articles.
Numerous authors maintain renowned the dearth of research focused on handoffs.45,57,70,83,85,86 In addition, there are risks involved in implementing interventions without evidence supporting their effectiveness.87 Winters and colleagues87(p1,647) renowned that “[n]ational efforts to better patient safety should subsist supported by sufficiently strong evidence to warrant such a commitment of resources.”
Evidence-based exercise is informed by high-quality research. Recent publication guidelines for patient safety and property initiatives maintain established a framework for standardized reporting.88,89 They recommend that future handoffs studies exhaust the Standards for property Improvement Reporting Excellence (SQUIRE) guidelines.89 Many of the studies reviewed here would maintain been improved by doing so.
Others maintain renowned that it may subsist unreasonable to hope patient safety and property studies to follow the design rigors of randomized controlled trials.87 However, the RAND/UCLA Appropriateness mode provides a structured, rigorous mode to synthesize data from other clinical study types with expert conviction to provide the best available guidelines.90 Unfortunately, the literature on handoffs identified here is not of enough property and quantity to synthesize into evidence-based recommendations.
Although the Joint Commission is calling for structured handoffs, they identified very exiguous evidence to advocate the exhaust of any specific structure, protocol, or method. However, direct observation of handoffs in other settings (i.e., NASA mission control, nuclear power, railroad, and ambulance dispatch) with towering consequences for error, yielded 21 common strategies,91 which could tender a starting point in the development of health saturate handoffs research. Their review of the U.S. physicians’ handoffs literature has led us to develop a list of research questions, organized by the content domains of knowledge, attitudes, skills, process outcomes, and clinical outcomes (see List 1).
Across the United States, hospitals are implementing structured handoff protocols in an exertion to comply with Joint Commission requirements. High-quality outcomes studies that focus on systems factors, human performance, and the effectiveness of protocols and interventions are urgently needed. These studies should address the barriers and strategies identified here. In addition, handoffs in different disciplines are likely to maintain different requirements and issues. For instance, an emergency department handoff will requisite to maintain different content than one for inpatient medicine or pediatrics. Therefore, researchers should conduct discipline-specific handoff studies.
We muster for rigorous outcomes studies designed to (1) assess the effectiveness of handoffs, (2) determine the elements of handoffs that lead to improved patient outcomes, and (3) identify the best implementation strategies. Finally, these studies should subsist reported using the SQUIRE guidelines. Without these studies, hospitals across the United States are destined to consume time, resources, and exertion on flawed handoff practices.
Special thanks to Ellen M. Justice, MLIS, AHIP, medical librarian of the Lewis B. Flinn Medical Library, Christiana saturate Health System, for conducting literature searches; Dolores Ann Moran, medical library coadjutant II, and Janice Evans, medical library coadjutant II, for their assistance in locating articles; and Donald Riesenberg, MD, for feedback on the manuscript.
1Chassin MR, Becher EC. The wrong patient. Ann Intern Med. 2002;136:826–833.
2Donchin Y, Gopher D, Olin M, et al. A spy into the nature and causes of human errors in the intensive saturate unit. Qual Saf Health Care. 2003;12:143–148.
3Beckman HB, Markakis KM, Suchman AL, Frankel RM. The doctor–patient relationship and malpractice: Lessons from plaintiff depositions. Arch Intern Med. 1994;154:1365–1370.
4White AA, Wright SW, Blanco R, et al. Cause-and-effect analysis of risk management files to assess patient saturate in the emergency department. Acad Emerg Med. 2004;11:1035–1041.
5White AA, Pichert JW, Bledsoe SH, Irwin C, Entman SS. intuition and result analysis of closed claims in obstetrics and gynecology. Obstet Gynecol. 2005;105:1031–1038.
7Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures: An insidious contributor to medical mishaps. Acad Med. 2004;79:186–194.
8Keyes C. Coordination of saturate provision: The role of the ‘handoff.’ Int J Qual Health Care. 2000;12:519.
9Volpp KGM, Grande D. Residents’ suggestions for reducing errors in teaching hospitals. N Engl J Med. 2003;348:851–855.
11Gandhi TK, Kachalia A, Thomas EJ, et al. Missed and delayed diagnoses in the ambulatory setting: A study of closed malpractice claims. Ann Intern Med. 2006;145:488–496.
12Kachalia A, Gandhi TK, Puopolo AL, et al. Missed and delayed diagnoses in the emergency department: A study of closed malpractice claims from 4 liability insurers. Ann Emerg Med. 2007;49:196–205.
13Greenberg CC, Regenbogen SE, Studdert DM, et al. Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg. 2007;204:533–540.
14Gawande AA, Zinner MJ, Studdert DM, Brennan TA. Analysis of errors reported by surgeons at three teaching hospitals. Surgery. 2003;133:614–621.
15Jagsi R, Kitch BT, Weinstein DF, Campbell EG, Hutter M, Weissman JS. Residents report on adverse events and their causes. Arch Intern Med. 2005;165:2607–2613.
16Agency for Healthcare property and Research. Hospital Survey on Patient Safety Culture: 2008 Comparative Database Report. Available at: http://www.ahrq.gov/qual/hospsurvey08. Accessed August 24, 2009.
17Sorokin R, Riggio JM, Hwang C. Attitudes about patient safety: A survey of physicians-in-training. Am J Med Qual. 2005;20:70–77.
18Fletcher KE, Parekh V, Halasyamani L, et al. drudgery hour rules and contributors to patient saturate mistakes: A focus group study with internal medicine residents. J Hosp Med. 2008;3:228–237.
19Fins JJ. Professional responsibility: A perspective on the Bell Commission reforms. Bull NY Acad Med. 1991;67:359–364.
20Barden CB, Specht MC, McCarter MD, Daly JM, Fahey TJ. Effects of limited drudgery hours on surgical training. J Am Coll Surg. 2002;195:531–538.
21Laine C, Goldman L, Soukup JR, Hayes JG. The repercussion of a regulation restricting medical house staff working hours on the property of patient care. JAMA. 1993;269:374–378.
22Petersen LA, Brennan TA, O’Neil AC, Cook EF, Lee TH. Does housestaff discontinuity of saturate extend the risk for preventable adverse events? Ann Intern Med. 1994;121:866–872.
23Charap M. Reducing resident drudgery hours: Unproven assumptions and unforeseen outcomes. Ann Intern Med. 2004;140:814–815.
24Buff DD, Shabti R. The night float system of resident on call: What achieve the nurses think? J Gen Intern Med. 1995;10:400–402.
25Gandhi TK. Fumbled handoffs: One dropped ball after another. Ann Intern Med. 2005;142:352–358.
26Coiera E. When conversation is better than computation. J Am Med Inform Assoc. 2000;7:277–286.
27Coiera EW, Jayasuriya RA, Hardy J, Bannan A, Thorpe MEC. Communication loads on clinical staff in the emergency department. Med J Aust. 2002;176:415–418.
28Coiera E, Tombs V. Communication behaviors in a hospital setting: An observational study. BMJ. 1998;316:673–676.
29Parker J, Coiera E. Improving clinical communication: A view from psychology. J Am Med Inform Assoc. 2000;7:453–461.
30DeFrances CJ, Lucas CA, Buie VC, Golosinskiy A. 2006 National Hospital Discharge Survey. National Health Statistics Report. July 30, 2008. Available at: http://www.cdc.gov/nchs/data/nhsr/nhsr005.pdf. Accessed August 24, 2009.
34Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological property both of randomised and non-randomised studies of health saturate interventions. J Epidemiol Community Health. 1998;52:377–384.
35West S, King V, Carey TS, et al. Systems to Rate the power of Scientific Evidence. Evidence Report/Technology Assessment No. 47 (Prepared by the Research Triangle Institute-University of North Carolina Evidence-based exercise heart under compress No. 290-97-0011). AHRQ Publication No. 02-E016. Rockville, MD: Agency for Healthcare Research and Quality. April 2002. Available at: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat1.chapter.70996. Accessed August 24, 2009.
36Deeks JJ, Dinnes J, D’Amico R, et al. Evaluating non-randomised intervention studies. Health Technology Assessment. 2003;7(27). Available at: http://www.ncchta.org/fullmono/mon727.pdf. Accessed August 24, 2009.
37Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15:1277–1288.
38Communication strategies for patient handoffs. Obstet Gynecol. 2007;109:1503–1505.
39Handoff information should cover past, future. Healthc Risk Manag. 2005;27:94.
40Measure understanding during handoffs: A naval hospital uses an evaluation instrument to determine whether information is understood. Brief Patient Saf. 2006:8–9.
41Patient handoff must subsist more than a formality. Healthc Risk Manag. 2005;27:93.
42Strategies for improving OR handoffs. OR Manager. 2005;21(8):9–10.
43What's wrong with this hand-off? Brief Patient Saf. 2006;7(1):9,12.
44Arora V, Johnson J. National patient safety goals. A model for building a standardized hand-off protocol. Jt Comm J Qual Patient Saf. 2006;32:646–655.
45Beach C, Croskerry P, Shapiro M. Profiles in patient safety: Emergency saturate transitions. Acad Emerg Med. 2003;10:364–347.
46Chacko V, Varvarelis N, Kemp DG. eHand-offs: An IBM Lotus Domino application for ensuring patient safety and enhancing resident supervision in hand-off communications. AMIA Annu Symp Proc. 2006:874.
47Dracup K, Morris PE. Passing the torch: The challenge of handoffs. Am J Crit Care. 2008;17:95–97.
48Frazer TS. “Doctor's notes”: A computerized mode for managing inpatient care. Fam Med. 1988;20:223–224.
49Goldman L, Pantilat SZ, Winthrop F, Whitcomb WF. Passing the clinical baton: 6 principles to usher the hospitalists. Am J Med. 2001;111(9B):36S–39S.
50Kushniruk A, Karson T, Moore C, Kannry J. From prototype to production system: Lessons erudite from the evolution of the SignOut System at Mount Sinai Medical Center. AMIA Annu Symp Proc. 2003:381–385.
51Landucci D, Gipe BT. The technique and science of the handoff: How hospitalists participate data. Hospitalist. 1999;3:4.
52Luo J, Hales RE, Hilty D, Brennan C. Clinical computing: Electronic sign-out using a personal digital assistant. Psychiatr Serv. 2001;52:173–174.
53Mukherjee S. A precarious exchange. N Engl J Med. 2004;351:1822–1824.
54Nemeth C, Nunnally M, O’Connor M, Cook R. Creating resilient IT: How the sign-out sheet shows clinicians do healthcare work. AMIA Annu Symp Proc. 2006:584–588.
55Sarkar U, Carter JT, Omachi TA, et al. SynopSIS: Integrating physician sign-out with the electronic medical record. J Hosp Med. 2007;2:336–342.
56Sutker WL. The physician's role in patient safety: What's in it for me? Baylor Univ Med Cent Proc. 2008;21:9–14.
57Vidyarthi AR, Arora V, Schnipper JL, Wall SD, Wachter RM. Managing discontinuity in academic medical centers: Strategies for a safe and efficient resident sign-out. J Hosp Med. 2006;1:257–266.
58Weinstock M. Transitioning care: H&HN′s ‘Saves Lives Now’ chain profiles a better course to ply patient handoffs. Hosp Health Netw. 2005;79(6):27–28.
59Haig KM, Sutton S, Whittington J. SBAR: A shared mental model for improving communication between clinicians. Jt Comm J Qual Patient Saf. 2006;32:167–175.
60Arora VM, Johnson JK, Meltzer DO, Humphrey HJ. A academic framework and competency-based approach to improving handoffs. Qual Saf Health Care. 2008;17:11–14.
61Singer JI, Dean J. Emergency physician intershift handovers: An analysis of their transitional care. Pediatr Emerg Care. 2006;22:751–754.
62Solet DJ, Norvell JM, Rutan GH, Frankel RM. Lost in translation: Challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med. 2005;80:1094–1099.
63Guise JM, Lowe NK. achieve you speak SBAR? J Obstet Gynecol Neonatal Nurs. 2006;35:313–314.
64Jauhar S. Patient handoffs, or walking along a narrow mountain ledge. Medscape J Med. 2008;10(3):57.
65Philibert I, Leach DC. Re-framing continuity of saturate for this century. Qual Saf Health Care. 2005;14:394–396.
66Lee LH, Levine JA, Schultz HJ. Utility of a standardized sign-out card for original medical interns. J Gen Intern Med. 1996;11:753–755.
67Van Eaton EG, Horvath KD, Lober WB, Rossini AH, Pellegrini CA. A randomized, controlled tribulation evaluating the repercussion of a computerized rounding and sign-out system on continuity of saturate and resident drudgery hours. J Am Coll Surg. 2005;200:538–545.
68Lofgren RP, Gottlieb D, Williams RA, wealthy EC. Post-call transfer of resident responsibility: Its result on patient care. J Gen Intern Med. 1990;5:501–505.
69Arora V, Kao J, Lovinger D, Seiden SC, Meltzer D. Medication discrepancies in resident sign-outs and their potential to harm. J Gen Intern Med. 2007;22:1751–1755.
70Borowitz SM, Waggoner-Fountain LA, Bass EJ, Sledd RM. Adequacy of information transferred at resident sign-out (inhospital handover of care): A prospective survey. Qual Saf Health Care. 2008;17:6–10.
71Frank G, Lawler LA, Jackson AA, Steinberg TH, Lawless ST. Resident miscommunication: Accuracy of the resident sign-out sheet. J Healthc Qual. 2005;27(2):(Web Exclusive):W2-10–W2-14. Available at: http://www.nahq.org/journal/online/pdf/webex0305.pdf. Accessed August 24, 2009.
72Horwitz LI, Krumholz HM, Green ML, Huot SJ. Transfers of patient saturate between house staff on internal medicine wards: A national survey. Arch Intern Med. 2006;166:1173–1177.
73Sinha M, Shriki J, Salness R, Blackburn PA. requisite for standardized sign-out in the emergency department: A survey of emergency medicine residency and pediatric emergency medicine fellowship program directors. Acad Emerg Med. 2007;14:192–196.
74Frank G, Lawless ST, Steinberg TH. Improving physician communication through an automated, integrated sign-out system. J Healthc Inf Manag. 2005;19(4):68–74.
75Horwitz LI, Moin T, Green ML. development and implementation of an oral sign-out skills curriculum. J Gen Intern Med. 2007;22:1470–1474.
76Kannry J, Moore C. MediSign: Using a Web-based SignOut System to better provider identification. Proc AMIA Symp. 1999:550–554.
77Petersen LA, Orav EJ, Teich JM, O’Neil AC, Brennan TA. Using a computerized sign-out program to better continuity of inpatient saturate and prevent adverse events. Jt Comm J Qual Improv. 1998;24:77–87.
78Ram R, secrete B. Signing out patients for off-hours coverage: Comparison of manual and computer-aided methods. Proc Annu Symp Comput Appl Med Care. 1992:114–118.
79Van Eaton EG, Horvath KD, Lober WB, Pellegrini CA. Organizing the transfer of patient saturate information: The development of a computerized resident sign-out system. Surgery. 2004;136:5–13.
80Apker J, Mallak LA, Gibson SC. Communicating in the “gray zone”: Perceptions about emergency physician–hospitalist handoffs and patient safety. Acad Emerg Med. 2007;14:884–894.
81Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Communication failures in patient sign-out and suggestions for improvement: A critical incident analysis. Qual Saf Health Care. 2005;14:401–407.
82Kellogg KC, Breen E, Ferzoco SJ, Zinner MJ, Ashley SW. Resistance to change in surgical residency: An ethnographic study of drudgery hours reform. J Am Coll Surg. 2006;202:630–636.
83Laxmisan A, Hakimzada F, Sayan OR, Green RA, Zhang J, Patel VL. The multitasking clinician: Decision-making and cognitive exact during and after team handoffs in emergency care. Int J Med Inform. 2007;76:801–811.
84Davidoff F, Batalden P. Toward stronger evidence on property improvement. Draft publication guidelines: The beginning of a consensus project. Qua Saf Health Care. 2005;14:319–325.
85Hamilton P, Gemeinhardt G, Mancuso P, Sahlin CL, Ivy L. SBAR and nurse–physician communication: Pilot testing an educational intervention. Nurs Adm Q. 2006;30:295–299.
86Pope BB, Rodzen L, Spross G. Raising the SBAR: How better communication improves patient outcomes. Nursing. 2008;38(3):41–43.
87Winters BD, Pham J, Pronovost PJ. Rapid response teams—Walk, don’t run. JAMA. 2006;296:1645–1647.
88Stevens DP. Why original guidelines for reporting improvement research? And why now? Qual Saf Health Care. 2005;14:314.
90Fitch K, Bernstein SJ, Aguilar MD, et al. The RAND/UCLA Appropriateness mode User's Manual. Santa Monica, Calif: RAND; 2001.
91Patterson ES, Roth EM, Woods DD, Chow R, Gomes JO. Handoff strategies in settings with towering consequences for failure: Lessons for health saturate operations. Int J Qual Health Care. 2004;16:125–132.
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Academic Medicine84(12):1775-1787, December 2009.
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