Teaching comprehension of double-meaning jokes to young children.

Various forms of humor are an important aspect of social interactions, even at an early age. Humor comprehension is a repertoire that is said to emerge between the ages of 7 and 11 years, and this is primarily attributed to a child's level of cognitive development. The behavioral literature has suggested that various forms of complex verbal behavior, including the use and comprehension of humor, are learned operants that can be taught using systematic teaching procedures. The current study used multiple exemplar training and a three-step error correction procedure to teach comprehension of double-meaning jokes to 4 children (2 females and 2 males) aged between 5 and 6.5 years old. All participants demonstrated humor comprehension and appreciation, across multiple exemplars, following training, and maintained this at follow-up. Implications for use with clinical populations are discussed.

A Safe-Word Intervention for Abduction Prevention in Children With Autism Spectrum Disorders.

Most abduction-prevention strategies focus on teaching children safe responses to lures from strangers; however, statistics suggest that the majority of nonfamily abductions are conducted by people who are, to some extent, familiar to the child. We evaluated the effects of a safe-word intervention to address this discrepancy and decrease the likelihood that a child will leave with a person not appointed by his or her parents, regardless of whether the person is familiar or unfamiliar to the child. Five children diagnosed with autism spectrum disorder, aged 4-9 years old, were taught a 4-part response to lures from familiar and unfamiliar adults using a behavioral skills training package with in situ training added as needed. All participants met initial mastery criteria, with 4 of the 5 children requiring the addition of in situ training, and all maintained mastery levels at a 2-month follow-up.

The Effects of Peer Presence on Variables Maintaining Moderate-to-Vigorous Physical Activity in Children.

An increasing number of children fail to meet the recommended levels of physical activity. The purpose of this study was to examine the effects of peer presence on variables that have been shown to evoke moderate-to-vigorous physical activity (MVPA) in children. We recorded the levels of MVPA in three preschool children across no adult, attention, and interactive play conditions, with a peer present and absent. All conditions were compared with a naturalistic baseline and presented in a multielement design with a brief reversal to baseline and reintroduction of the most effective condition. All three participants displayed most MVPA during the interactive play condition with a peer present. This study furthers research on the identification of variables that evoke MVPA in young children and emphasizes the interaction of peer presence and contingent social positive reinforcement as relevant variables.

Unanticipated hospital admissions during or soon after radiation therapy: Incidence and predictive factors.

PURPOSE: Unplanned hospital admissions in cancer patients undergoing treatment is an understudied area with important implications for both health care costs and patient outcomes. The goal of this retrospective study was to evaluate the rate, reasons for, and predictors of unplanned hospital admissions during or soon after palliative or curative radiation therapy for cancer, with or without chemotherapy. METHODS AND MATERIALS: A total of 1116 consecutive patients who received external beam radiation therapy for a malignancy at the University of North Carolina at Chapel Hill from January 1 through December 31, 2010, were studied. The primary outcome was unplanned hospitalization within 90 days of starting radiation therapy (ie, during or soon after). Multivariable logistic regression was used to examine patient and treatment factors associated with admissions. RESULTS: Twenty percent of patients experienced an unplanned admission, which was especially likely in patients with lung (25% of such patients admitted), head and neck (22%), and gastrointestinal (21%) cancers, as well as those treated with palliative intent (31%). The most common causes for admission were gastrointestinal symptoms, neurologic symptoms, respiratory symptoms, pain, and fever or infection. Forty-seven percent of admitted patients were seen in the clinic within 2 weeks of unplanned hospital admission, and 61% of those patients had a related complaint in the clinic. Multivariate analysis showed that married patients (odds ratio [OR] = 0.58; P < .001), curative intent (OR = 0.38; P < .001), and no concurrent chemotherapy (OR = 0.55; P < .001) were associated with decreased odds for admission. CONCLUSIONS: Unplanned admissions are relatively common during or soon after radiation therapy in our patient series. Additional work is needed to gather data from other centers and to better understand, and hopefully reduce, these unplanned admissions.

Quantification of the impact of multifaceted initiatives intended to improve operational efficiency and the safety culture: a case study from an academic medical center radiation oncology department.

PURPOSE: We have systematically been incorporating several operational efficiency and safety initiatives into our academic radiation oncology clinic. We herein quantify the impact of these initiatives on prospectively collected, clinically meaningful, metrics. METHODS AND MATERIALS: The data from 5 quality improvement initiatives, each focused on a specific safety/process concern in our clinic, are presented. Data was collected prospectively: operational metrics recorded before and after implementation of the initiative were compared using statistical analysis. Results from the Agency for Health Care Research and Quality (AHRQ) patient safety culture surveys administered during and after many of these initiatives were similarly compared. RESULTS: (1) Workload levels for nurses assisting with brachytherapy were high (National Aeronautics and Space Administration Task Load Index (NASA-TLX) scores >55-60, suggesting, "overwork"). Changes in work flow and procedure room layout reduced workload to more acceptable levels (NASA-TLX <55; P < .01). (2) The rate of treatment therapists being interrupted was reduced from a mean of 4 (range, 1-11) times per patient treatment to a mean <1 (range, 0-3; P < .001) after implementing standards for electronic communication and placement of monitors informing patients and staff of the treatment machine status (ie, delayed, on time). (3) The rates of replans by dosimetrists was reduced from 11% to 6% (P < .01) through a more systematic pretreatment peer review process. (4) Standardizing nursing and resident functions reduced patient wait times by ≈ 45% (14 min; P < .01). (5) Standardizing presimulation instructions from the physician reduced the number of patients experiencing delays on the simulator (>50% to <10%; P < .01). To assess the overall changes in "patient safety culture," we conducted a pre- and postanalysis using the AHRQ survey. Improvements in all measured dimensions were noted. CONCLUSIONS: Quality improvement initiatives can be successfully implemented in an academic radiation oncology department to yield measurable improvements in operations resulting in improvement in patient safety culture.

Brief report: An evaluation of TAGteach components to decrease toe-walking in a 4-year-old child with autism.

The current study evaluated the effectiveness of using a modified TAGteach procedure and correction to decrease toe-walking in a 4-year-old boy with autism. Two conditions were analyzed: correction alone and correction with an audible conditioned reinforcing stimulus. Correction alone produced minimal and inconsistent decreases in toe-walking but correction with an audible conditioned stimulus proved most effective in reducing this behavior. This has implications for decreasing toe-walking in other children with autism and may be easily used by teachers and parents.

Quantitative assessment of workload and stressors in clinical radiation oncology.

PURPOSE: Workload level and sources of stressors have been implicated as sources of error in multiple settings. We assessed workload levels and sources of stressors among radiation oncology professionals. Furthermore, we explored the potential association between workload and the frequency of reported radiotherapy incidents by the World Health Organization (WHO). METHODS AND MATERIALS: Data collection was aimed at various tasks performed by 21 study participants from different radiation oncology professional subgroups (simulation therapists, radiation therapists, physicists, dosimetrists, and physicians). Workload was assessed using National Aeronautics and Space Administration Task-Load Index (NASA TLX). Sources of stressors were quantified using observational methods and segregated using a standard taxonomy. Comparisons between professional subgroups and tasks were made using analysis of variance ANOVA, multivariate ANOVA, and Duncan test. An association between workload levels (NASA TLX) and the frequency of radiotherapy incidents (WHO incidents) was explored (Pearson correlation test). RESULTS: A total of 173 workload assessments were obtained. Overall, simulation therapists had relatively low workloads (NASA TLX range, 30-36), and physicists had relatively high workloads (NASA TLX range, 51-63). NASA TLX scores for physicians, radiation therapists, and dosimetrists ranged from 40-52. There was marked intertask/professional subgroup variation (P<.0001). Mental demand (P<.001), physical demand (P=.001), and effort (P=.006) significantly differed among professional subgroups. Typically, there were 3-5 stressors per cycle of analyzed tasks with the following distribution: interruptions (41.4%), time factors (17%), technical factors (13.6%), teamwork issues (11.6%), patient factors (9.0%), and environmental factors (7.4%). A positive association between workload and frequency of reported radiotherapy incidents by the WHO was found (r = 0.87, P value=.045). CONCLUSIONS: Workload level and sources of stressors vary among professional subgroups. Understanding the factors that influence these findings can guide adjustments to the workflow procedures, physical layout, and/or communication protocols to enhance safety. Additional evaluations are needed in order to better understand if these findings are systemic.

Improving quality of patient care by improving daily practice in radiation oncology.

Radiation oncology is an ever-advancing, complex, technologically based specialty that has been thrust into the public spotlight because of recent reports of serious treatment delivery errors that have impacted the quality of patient care. Although quality assurance (QA) initiatives are already common place in radiation oncology, the continued complex technology and automation-based advances in radiotherapy have created new safety challenges. The ongoing evolution of safety challenges in radiation oncology requires corresponding evolution in workflow and QA programs to ensure the quality of patient care. We believe that the incorporation of QA themes into our daily practice will help to create safer patient environments. Practical QA approaches that can be readily incorporated and applied in the daily practice of radiation oncology include process engineering and human factors engineering, medical peer review, "safety rounds," and software QA tools. Most importantly, we need to develop a culture of safety in which all team members work together to maximize the quality of our patient care.

The challenge of maximizing safety in radiation oncology.

There is a growing interest in the evolving nature of safety challenges in radiation oncology. Understandably, there has been a great deal of focus on the mechanical and computer aspects of new high-technology treatments (eg, intensity-modulated radiation therapy). However, safety concerns are not limited to dose calculations and data transfer associated with advanced technologies. They also stem from fundamental changes in our workflow (eg, multiple hand-offs), the relative loss of some traditional "end of the line" quality assurance tools (port films and light fields), condensed fractionation schedules, and an under-appreciation for the physical limitations of new techniques. Furthermore, changes in our workspace and tools (eg, electronic records, planning systems), and workloads (eg, billing, insurance, regulations) may have unforeseen effects on safety. Safety initiatives need to acknowledge the multiple factors affecting risk. Our current challenges will not be adequately addressed simply by defining new policies and procedures. Rather, we need to understand the frequency and causes of errors better, particularly those that are most likely to cause harm. Then we can incorporate principles into our workspace that minimize these risks (eg, automation, standardization, checklists, redundancy, and consideration of "human factors" in the design of products and workspaces). Opportunities to enhance safety involve providing support through diligent examinations of staffing, schedules, communications, teamwork, and work environments. We need to develop a culture of safety in which all team members are alerted to the possibility of harm, and they all work together to maximize safety. The goal is not to eliminate every error. Rather, we should focus our attention on conditions (eg, rushing) that can cause real patient harm, and/or those conditions that reflect systemic problems that might lead to errors more likely to cause harm. Ongoing changes in clinical practice mandate continued vigilance to minimize the risks of error, combined with new, nontraditional approaches to create a safer patient environment.