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Focusing on the principles of physiological interpretation of CTG, this new edition promotes an evidence-based approach to interpreting fetal heart rate changes. Traditional classification systems are arbitrary and associated with increased caesarean sections without improvements in perinatal outcomes. Guiding the reader in the use of novel tools to help eliminate avoidable, intrapartum-related fetal hypoxic-ischaemic brain injuries and their long term consequences such as cerebral palsy and learning difficulties, this book moves away from traditional, illogical classification systems. Topics such as non-hypoxic causes of fetal brain injury, types of intrapartum hypoxia, and medico-legal issues are clearly explained, and new chapters on human factors in CTG interpretation and the development of new technologies that can reduce human errors are included. Methods discussed comply with the International Expert Consensus Statement on Physiological Interpretation of CTG (October 2024), authored by over 50 CTG experts from over 20 countries.
Edited by
Liz McDonald, East London NHS Foundation Trust,Roch Cantwell, Perinatal Mental Health Service and West of Scotland Mother & Baby Unit,Ian Jones, Cardiff University
Difficult lessons from the Confidential Enquiries into Maternal Deaths remind us that thorough clinical assessment, detailed mental state examination and an appreciation of the dynamic nature of risk and its management are central to the effective treatment of women with perinatal mental illness. This is underpinned by the establishment of a trusting, respectful and honest relationship with the woman, which sees her as a partner in decision-making, and a detailed knowledge of the distinctive presentations and risks associated with illness in pregnancy and after childbirth, and its consequences for the woman and her infant.
Edited by
Liz McDonald, East London NHS Foundation Trust,Roch Cantwell, Perinatal Mental Health Service and West of Scotland Mother & Baby Unit,Ian Jones, Cardiff University
Suicide remains a leading cause of maternal death in the UK and in other high-income countries. While there are clear risks in severe mental disorder, those who die have experienced a range of mental illnesses and often come from more deprived communities. The Confidential Enquiries highlight the distinctive patterns of occurrence and progression in perinatal mental illness and the need for improvements in clinical evaluation of risk, effective risk management and the availability of high-quality perinatal mental healthcare as important factors in helping reduce progression to suicide.
Governance structures in radiotherapy are central to ensuring patient safety, yet significant variation exists in how errors are reported, analysed and mitigated globally. This literature review evaluates current international approaches to radiotherapy error governance, highlighting barriers to consistent reporting and opportunities for system-wide improvement.
Methods:
A structured search of peer-reviewed literature and policy documents was undertaken using a Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. The search yielded 42 relevant articles, reviewed for themes relating to governance frameworks, safety culture, incident reporting systems and technology’s role in error reduction.
Results:
Findings reveal inconsistent adoption of Safety I and Safety II models, underreporting due to blame culture, and limited integration of artificial intelligence (AI) into governance frameworks. Successful strategies included pre-treatment peer review, multidisciplinary safety boards and AI-assisted risk management tools. Despite advancements, gaps persist in standardising incident definitions, fostering transparency and promoting a just culture.
Conclusion:
The review suggests the need for international alignment on governance practices, wider integration of AI and proactive learning from near misses. Radiographers and radiation oncology teams are urged to engage in shaping safety governance through open reporting, system design and education. Implications for practice: Improved governance not only reduces harm but also supports continuous quality improvement in radiotherapy services.
The chapter analyses how the climate change action plan developed by the European Central Bank (ECB) as part of its monetary policy strategy review in 2020-2021 is aligned with the ECB’s mandate set out in the Treaty on the Functioning of the European Union and the Treaty on European Union. The Treaties require the ECB to integrate climate change considerations into its monetary policy and to contribute to the EU’s objectives regarding climate change, as established by Regulation (EU) 2021/1119, the European Climate Law. However, there are also legal limits on the action the ECB can take in this field. The chapter examines the key measures proposed as part of the plan from a legal perspective, including measures related to macroeconomic forecasts and models, the collection of statistical information for climate change risk analysis, the enhancement of risk assessment capabilities, asset purchase programmes, and possible changes to the collateral framework. It also considers the questions regarding the ECB’s democratic legitimacy and accountability that arise in this context.
Person-centered care that honors individual preferences can improve the well-being of nursing home (NH) residents with Alzheimer’s disease and related dementias (ADRD). However, preferences such as going outside independently are often restricted due to perceived safety risks. There is a critical need for strategies that help NH staff balance safety concerns with residents’ autonomy.
Materials and methods:
We developed the Decision-making In aGing and demeNtIa for autonomy (DIGNITY) intervention using the Community-Engaged Intervention Mapping (CEIM) Model. This multilevel, theory informed program was codesigned with NH stakeholders to support shared decision-making and promote preference-congruent dementia care.
Results:
A total of 53 stakeholders participated in focus groups and engagement sessions. Feedback informed six key refinements to the DIGNITY program: manual formatting, communication strategies, staff role delineation, addressing resident decision-making capacity, and identifying implementation barriers and facilitators. The final intervention includes a structured manual, decision-making tools, and a training and coaching program to support NH staff in honoring resident preferences while managing perceived risks.
Conclusion:
DIGNITY is a novel, stakeholder-informed intervention designed to support preference-based dementia care in rural NHs. Future research should assess its feasibility, acceptability, and impact on staff attitudes and resident outcomes.
In two fields that are currently of high political salience and strategic significance – the regulation of digital platforms, and the regulation of environmental and human rights impacts in global value chains – the EU has taken a strikingly similar regulatory approach. In the 2022 Digital Services Act and the 2024 Corporate Sustainability Due Diligence Directive, it has charged large companies with managing risks to various public values and concerns. In this contribution, we critique this shared regulatory approach. First, we argue that regulating dominant corporations via risk management obligations actually reinforces their power in three ways: it is inherently deferential to corporate power and profitability; it reinforces technocratic framings of policy problems which discourage political contestation of economic governance; and it allows corporations to evade responsibility by framing negative impacts of their activities as external problems against which they protect the public. Second, these problem framings shape the implementation as well as the content of regulations. Specifically, they direct compliance and enforcement efforts to procedure over substance; and create significant practical barriers to public and private enforcement. We conclude by discussing the implications of our analysis in the context of the EU’s current deregulatory agenda.
This chapter examines the challenges and risks within China’s real estate sector, a cornerstone of its hybrid economy that blends state intervention with market dynamics. The analysis highlights how local governments’ heavy reliance on land sales and debt financing has spurred over-investment and elevated leverage, creating systemic risks for both the financial system and broader economic growth. It discusses the roles of various channels – financing, tournament, and central government guarantees – in exacerbating market distortions and encouraging speculative behavior. The chapter also reviews recent market trends during the COVID-19 period, revealing significant mismatches between demand, supply, and pricing across different city tiers. While government interventions have successfully postponed a hard landing, they may not address underlying structural issues. Ultimately, the chapter argues that sustainable risk mitigation in the real estate sector requires structural reforms and the development of new economic growth engines to reduce over-dependence on real estate.
Intrapartum events have resulted in maternal and perinatal morbidity and mortality and rising medico-legal claims related to maternity. Despite rapid technological advances recently, the rates of clinical incidents such as PPH, OASI and adverse fetal outcomes have not reduced significantly. Furthermore, new intrapartum incidents such as impacted fetal head, caring for mothers with high BMI and managing extreme preterm labour are on the rise. Empowering patients and their unrealistic expectations and workforce issues further complicate this issue. Many reports have indicated more than 50% of these are preventable. Various strategies at the institutional, process and clinical levels used to minimise labour risk are discussed. Some include staff numbers, fatigue, skill mix, training, guidelines, algorithms and partnership with patents. Interventions to reduce a few clinical conditions are discussed. We made suggestions based on pilot studies on how we could improve intrapartum care using modern technology, including AI.
The increase in activities related to unmanned aircraft systems and the implementation of this new ecosystem have introduced new hazards, impacting the operational safety of air traffic, particularly near airports, creating risks and disruptions in the flow of aircraft. The establishment of airspace for unmanned traffic management has required the integration of this new airspace with the existing one, bringing the potential for issues from this integration. A method was identified as needed to guide the detection of hazards posed to air traffic control activities and the consequent implementation of required mitigation measures. The aim of this work is to propose a framework for identifying hazards introduced to air traffic control, with a view to ensure the safe transition of this process. The method involved consulting air traffic operational safety specialists via a questionnaire, presenting the hazards highlighted in the literature concerning the integration of new airspace concepts within air traffic control activities. The results, obtained through a Delphi consultation, were analysed based on the most frequently assigned scores (mode) to reflect expert consensus. The results were organised into the proposed framework, establishing a guide to risk management activities aimed at implementing the change. The resulting structure was re-submitted to specialists and validated based on the Delphi method. Contributions to society include a guide for this process and potential future implementations, while the literature gap was addressed by adding knowledge to the scientific process.
We examine the arguments made by Onitiu and colleagues concerning the need to adopt a “backward-walking logic” to manage the risks arising from the use of Large Language Models (LLMs) adapted for a medical purpose. We examine what lessons can be learned from existing multi-use technologies and applied to specialized LLMs, notwithstanding their novelty, and explore the appropriate respective roles of device providers and regulators within the ecosystem of technological oversight.
This paper presents two studies with packaging design engineers and quality and risk professionals in the pharmaceutical packaging industry, addressing the critical need for design support. The studies contribute to the development of a framework aimed at balancing risk management and multi-user experience in the context of product support. A review of prior work highlights the gap in tailored support for designers in this field. Using structured interviews and thematic analysis, seven key requirements were identified to guide the framework’s creation. A user persona was also developed, capturing the core responsibilities, challenges, and motivations of quality and risk professionals. These findings provide actionable insights to aid designers address complex regulatory and user-centric challenges, paving the way for innovation and improved outcomes in pharmaceutical packaging design.
This systematic literature review comprehensively assesses the risks associated with implementing Industry 4.0/5.0 technologies. It clusters these risks into six groups (strategic, financial, operational, technological, environmental, and sociocultural). Using a PRISMA-guided approach, the analysis of 83 peer-reviewed papers identified 36 unique risks out of a total of 811. The findings reveal critical challenges, including in cybersecurity threats, financial burdens, technological obsolescence, and workforce adaptation. These results provide a structured risk categorization that can assist enterprises, in effectively mitigating risks and aligning their strategies with Industry 4.0/5.0 transitions. This framework closes knowledge gaps and offers actionable insights for a robust and sustainable implementation.
To meet the upcoming sustainability challenges, aerospace manufacturers need to develop products that both address complex sustainability factors and ensure profitable realization. Furthermore, the sustainability perspective needs to be lifted from focusing on carbon emissions, and broadened to include a system-level socio-ecological view. Manufacturers are thus challenged to balance sustainability, manufacturability, and performance, but lack the methods and tools to make well-informed decisions. We propose a method for conducting multi-domain trade-off studies in the early design phase. A functional architecture modelling approach is utilized to model performance and manufacturing aspects. Together with a relative sustainability fingerprint conducted on design alternatives, design spaces can be explored with respect to performance, manufacturability, and sustainability.
The increasing complexity and connectivity of the mobility system and modern automotive systems, particularly connected autonomous vehicles, demand a paradigm shift toward resilience-by-design to address disruptions in dynamic environments. Unlike established safety and cybersecurity engineering in automotive, resilience engineering has yet to be systematically integrated into development processes. This paper defines resilience using a standard-based definition method, emphasizing disruption tolerance, adaptability, and recoverability. We identify action fields to advance the topic and propose a resilience-by-design framework extending safety and cybersecurity perspectives. Resilience-by-design offers strategies and methods to design robust, adaptive systems, ensuring reliability and availability of automotive systems, functions, and components in operation.
Unintended technical interactions across system interfaces can lead to costly failures and rework, particularly in the early design stages of complex products. This study examines how structured risk assessment tools influence teams’ ability to identify, evaluate and mitigate risks from such indirect interactions. In a controlled experiment, 14 engineering teams (comprising professionals and graduate students) engaged in simulated design decisions across three system configurations. Tool usage – including models of direct and indirect risk propagation and value-based trade-offs – was continuously logged and linked to outcomes. Teams that engaged earlier and more deliberately with the tools identified risks sooner and selected mitigation actions with more favourable cost–benefit profiles. Results show that strategic, not merely frequent, tool use improves risk management performance, particularly when addressing cascading effects from indirect physical interactions. These findings support the use of structured supports to enhance both the efficiency of early-stage risk evaluation and the efficacy of risk treatment.
Working conditions in psychiatry have worsened in many healthcare systems, allowing less time for person-centred care. There is a conflict between management and clinical values. Though IT carries great potential, many current systems fail to free up time for human-to-human contact. All these factors affect retention.
The ever-increasing expectation towards psychiatry to prevent suicides has taken to mean complete elimination in some places. This is problematic as suicide is not completely preventable; it is not a form of harm equivalent to other patient safety errors; and there is a plurality of relevant values. The impact on ‘second victims’ is also an important issue.
Owing to its relatively undeveloped conceptual foundations, psychiatry has often struggled to defend itself against various criticisms. A VBP-based analysis of the terminal and instrumental values of anti-psychiatry can highlight some of the weaknesses of its arguments. Critical psychiatry draws attention to problematic areas of psychiatric theory and practice to provide constructive criticism. Remarkably, much of that has now been adopted by mainstream psychiatry. A self-reflective stance and constructive criticism play an important role in keeping our profession on a sound ethical footing. A genuine dialogue about values among all stakeholders is needed for constant calibration.
This is a masters-level overview of the mathematical concepts needed to fully grasp the art of derivatives pricing, and a must-have for anyone considering a career in quantitative finance in industry or academia. Starting from the foundations of probability, this textbook allows students with limited technical background to build a solid knowledge of the most important principles. It offers a unique compromise between intuition and mathematics, even when discussing abstract ideas such as change of measure. Mathematical concepts are introduced initially using toy examples, before moving on to examples of finance cases, both in discrete and continuous time. Throughout, numerical applications and simulations illuminate the analytical results. The end-of-chapter exercises test students' understanding, with solved exercises at the end of each part to aid self-study. Additional resources are available online, including slides, code and an interactive app.
This paper examines in what way providers of specialized Large Language Models (LLM) pre-trained and/or fine-tuned on medical data, conduct risk management, define, estimate, mitigate and monitor safety risks under the EU Medical Device Regulation (MDR). Using the example of an Artificial Intelligence (AI)-based medical device for lung cancer detection, we review the current risk management process in the MDR entailing a “forward-walking” approach for providers articulating the medical device’s clear intended use, and moving on sequentially along the definition, mitigation, and monitoring of risks. We note that the forward-walking approach clashes with the MDR requirement for articulating an intended use, as well as circumvents providers reasoning around the risks of specialised LLMs. The forward-walking approach inadvertently introduces different intended users, new hazards for risk control and use cases, producing unclear and incomplete risk management for the safety of LLMs. Our contribution is that the MDR risk management framework requires a backward-walking logic. This concept, similar to the notion of “backward-reasoning” in computer science, entails sub-goals for providers to examine a system’s intended user(s), risks of new hazards and different use cases and then reason around the task-specific options, inherent risks at scale and trade-offs for risk management.
from
Section 4
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Walking the Walk (and Talking the Talk)
William Fawcett, Royal Surrey County Hospital, Guildford and University of Surrey,Olivia Dow, Guy's and St Thomas' NHS Foundation Trust, London,Judith Dinsmore, St George's Hospital, London
Anaesthesia has expanded outside of the operating theatre to encompass both intensive care medicine and pain medicine, but in addition over the last 10 years or so, the anaesthetist’s role has been redefined as a perioperative physician.
As a result, anaesthetists now have major input into preoperative assessment and preparation of patients for major surgery, optimizing medical conditions such as diabetes l and anaemia (including in iron therapy for the latter). Patients may also require referral to a high risk anaesthetic clinic (HRAC). Here they may also undergo risk stratification, so that the most appropriate surgery and care is provided including postoperative care. This may include preoperative cardiopulmonary exercise testing (CPET).
A major area of current interest is prehabilitation for some surgeries, and following chemotherapy. This involves improving preoperative aerobic fitness, nutrition and psychology to improve outcome.
Postoperatively, there is a focus not only the provision of oxygen therapy and fluids analgesia (with PONV prophylaxis), but also on thromboprophylaxis and appropriate antibiotics. In particular patients should be able to partake in early drinking, eating and mobilization, which itself requires avoidance of prolonged iv fluids, urinary catheters, NG tubes and surgical drains.
Finally early recognition and appropriate management of both surgical and medical complications is paramount.