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Week4 Project

December 15, 2023/in Uncategorized /by Daniel Jennings

Health Policy Project

Based on YOUR program of study, review the literature and address ONE the following:

• FNP/AGNP: Medicare reimbursement for NPs is 85% for the same health care that MDs receive at 100% reimbursement? Please address questions below and state your position on this mandate. (PREFER THIS ONE)
– Or –
• FNP/AGNP: What states have NP Full Practice Authority and which states have limitations or restrictions? How does this apply to your state? Please address these questions and state your position on the regulation within your state.

• Nurse Executive: What is value based care and how will it impact decisions made at the executive level relative to nursing and AP nursing? Please address and state your position on the regulation.

• Nurse Informaticists: What law(s) was/were enacted to regulate health information? Please address and state your position on this regulation.

• Nurse Educator: What agency regulates nursing education? Explain in detail.

For the above assignment, use the following guide:

Describe the current policy/status, which organization regulates and determine if it needs to change; if opposed to change, state why.
Provide the process required to make the change with key players and parties of interest; identify the groups who are opposed
Explain how AP roles (which ones) could lead the effort to make or influence the change in policy or keep the policy the same and the impact in healthcare quality.

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Rhetorical Essay

December 15, 2023/in Uncategorized /by Daniel Jennings

ENG 111 1

Assignment #2. Rhetorical Analysis

Due: December 3 (Thursday) 9:00 PM on Blackboard (20% of your final grade)

This assignment asks you to produce a rhetorical analysis essay of 750-1000 words. Your paper

must be a response to one of the essays or articles we read in class. You do not have to agree

with the original text, but you must analyze the text in depth in order to respond critically to it.

Note that your job in this assignment is NOT to express an opinion about the subject matter, but

to explain the efficiency of the writing strategies that are used in the text. You can consider the

traditional appeals of logos, ethos, and pathos; however, for the purpose of this assignment,

consider examining the rhetorical situations from various perspectives, including purpose,

audience, word choice, tone, effectiveness of rhetorical devices (e.g. use of anecdotes/ statistics/

pictures), and effectiveness of writing patterns (e.g. definition/ comparison/ contrast/

classification) in the essay of your choice.

For this assignment, you should use at least one outside source to support your analysis beyond

the piece you have chosen to analyze. You can use this additional source to either criticize or

support the original essay or article. Your critical response should have a clear point to make

about the original text and should be supported by reasons and evidence. In other words, you will

make an argument about someone else’s argument. Whenever necessary, you can use direct

quotations to elucidate your point; however, do not use block quotations (a long quotation that is

more than four lines and is set off from the text by indenting) in your essay.

The original text and any outside source(s)must be documented in MLA style, with in-text

citations and a Works Cited page. The Works Cited page does not count toward the word count.

All pages should be numbered and your name should be printed on each page. On the top of the

first page, put your name, my name, the course number (ENG 111), and the date of submission.

Your essay should be word-processed in 2.0 line spacing and 12-point Times New Roman, with

1″ margin. Please feel free to e-mail me (yshin@ccm.edu) if you have any questions.

Articles You Can Choose for this Assignment:

Any essay we’ve studied during the first four weeks [Welty, Didion, Kingston, Thiong’o, Rodriguez, Rose, Bolina, Williams]

ENG 111 2

Sample Rhetorical Analysis 1

Gavin M.

Dr. Clavin

ENG 111

November 19, 2018

Critical Response on Mike Rose’s “Blue-Collar Brilliance”

Judging a person’s intellectual ability based on their occupation is a common and

naturally occuring thought in our society. By seeing what a person does to make a living for

themselves, one can instantly presume the intelligence level of another. This action of judging

someone’s intellect based on their job is something that writer and UCLA professor Mike Rose

has had an issue with. In the article “Blue-Collar Brilliance” Rose argues that by making the

presumption about someone’s cognitive ability, people “reinforce social separations and cripple

our ability to talk across cultural divides” (Rose 456). Basically, by prejudging someone’s

intelligence, people are limiting the sharing of the diverse knowledge that our society provides.

Rose analyzes this issue with stories of personal experience, clear and persuasive language, and

consideration of multiple perspectives.

He begins the article with a story about his childhood and humble beginnings. Being that

his mother was a waitress, this is considered a blue-collar job, and Rose recalls he “would

occasionally hang out at the restaurant until her shift was ended, then we’d ride the bus home

with her” (Rose 449). By introducing his argument with a childhood story, Rose is attempting to

sway the reader with an emotional connection. He is looking for the reader to relate to him by

noting nostalgic memories of seeing his mother work. Rose is also attempting to make the reader

ENG 111 3

empathize with his mother and her job. By encompassing the reader’s emotions, the stories he

writes about keep the reader engaged throughout the article.

In the latter half of the article, Rose invokes another personal story about his hard-

working family member, Joe. With this story, Rose takes a somewhat different approach.

Because it is a matter of fact, this story more clearly and logically relates to his argument than

the previous. For example, Rose claims Joe “left school in ninth grade to work for the

Pennsylvania Railroad…and eventually joined his older brother at General Motors, over a 33

year career” (Rose 452). This is a sequential list of the events that led to Joe’s career, instead of a

story with sensory details. He then goes on to explain the immense amount of learning that Joe

had to go through while working in a factory. He claims Joe “learned more and more about the

auto industry, the technological and social dynamics of the shop floor, the machinery and

production processes, and the basics of paint chemistry and of plating and baking” (Rose 453).

By naming multiple concepts that Joe had learned, Rose is showing the reader that blue-collar

workers are capable of learning many different subjects. Through the telling of personal stories,

Mike Rose engages the reader logically and emotionally to help explain his argument.

The language utilized by Mike Rose in his article “Blue-Collar Brilliance” helps the

reader understand his argument more clearly. As he begins his article with a story about his

childhood, Rose uses sensory details to help the reader gain an image in their mind of what he is

trying to portray. For example, when describing his mother’s job he explains “pencil poised over

pad, while fielding questions about the food. She walked full tilt through the room with plates

stretching up her left arm and two cups of coffee somehow cradled in her right hand” (Rose 450).

This description and use of specific details helps the reader envision what it would have been

like to be in Rose’s mother’s position as a waitress. Rose also uses concise language to more

ENG 111 4

clearly make his point to the reader. For example, Rose claims “Generalizations about

intelligence, work, and social class deeply affect our assumptions about ourselves and each other,

guiding the ways we use our minds to learn, build knowledge, solve problems, and make our

way through the world” (Rose 452). He clearly states his argument and provides his reasoning in

a sequential order, making it easy for the reader to understand his position.

Rose also effectively makes his argument without showing bias to any one group of

people by explaining his multiple perspectives. Although his mother worked a blue-collar job

and lacked much formal education, Rose was different. He “studied the humanities and later the

social and psychological sciences and taught for 10 years in a range of situations” (Rose 451).

This shows that he is not only capable of arguing for the importance of blue-collar jobs, but also

has much experience in having a white-collar job and teaching formal education. Knowing this

helps the reader trust that there is no bias and that he is experienced with both sides of the

argument. He ultimately argues that people who work in blue-collar fields are not necessarily

less intelligent than those who work in white-collar fields.

Although Rose effectively makes his argument clear to the reader, there is room for more

explanation of his viewpoints. After describing his story through schooling, he subtly downplays

the importance of formal education. Rose discusses how blue-collar workers learn just as much

and are as intelligent as many white-collar workers. By doing this, he sways the reader to

devalue formal education. In an article composed by Moses C. Simuyemba, he emphasizes that

“Formal education is important not only because of what you are taught specifically, but for

other reasons as well such as what it builds into your character, personality and way of thinking”

(Simuyemba). By not explaining this viewpoint, Rose is overlooking the necessity of formal

education.

ENG 111 5

Workers of the white-collar and blue-collar nature prove to be very hard working people.

However, the white-collar workers tend to diminish the intelligence of the blue-collar worker

because of prejudice and assumption, according to Mike Rose. Given that he has an immense

amount of formal education and is a white-collar worker, it is somewhat surprising that he is

defending those on the opposite end of the spectrum. However, coming from a blue collar family

gives him the perspective of someone in that line of work in “Blue-Collar Brilliance”, Rose

effectively argues to the reader how the level of intelligence and problem-solving within the

blue-collar working community can be comparable to that of the white-collar community.

ENG 111 6

Works Cited

Note: Works Cited should be put on a separate page (it is included here on the last page to

save paper.

Rose, Mike. “Blue-Collar Brilliance.” The Norton Reader: An Anthology of Nonfiction, edited by

Melissa A. Goldthwaite et al., 14th ed., W. W. Norton, 2017, pp.449-56.

<- Indent the bibliographic information so that the author’s last name is the only text that

is flush left. Here’s how to indent: select the paragraph -> right click and choose

“Paragraph” -> go to “Indentation” in the middle of “Indents and Spring” (first

section) -> choose “Hanging” in “Special.”

Simuyemba, Moses. “The Value of a Formal Education.” AuthorsDen.com, Publish America,

authorsden.com/visit/viewarticle.asp?id=48821. Accessed 19 Nov. 2018.

ENG 111 7

Sample Rhetorical Analysis 2

Sandra B.

Dr. Clavin

English 111

October 29, 2018

Blue Collar Breakdown

Ever since childhood, people are taught that the more they learn, the more they earn in

the future. The formula is surprisingly, stupidly, and deviously simple: the parents tell their child

to study hard, go to school, become a doctor or engineer, get showered with money, and live a

good life. Success is supposedly paved with a college degree. Unfortunately, this formula to

success does not fit most Americans. Many people often find themselves along the path of life

working at either a service or trade job. People in service jobs are found everywhere, yet receive

little acknowledgement: the girl in the coffee shop; the boy in Auto Service; the men in the

factories. Most academics, and likewise, most Americans, claim that service work is for the ones

who throw their education away into a trash can of dreams broken by laziness (Kennedy). Mike

Rose is not one of these academics. His article “Blue Collar Brilliance” confronts the myth of

the average, molasses-minded, simpleton worker by providing a new perspective. Throughout

the text, he solidifies that workers are a lot smarter than they seem through a mix of personal

history, examples from his research, and academic analysis.

Rose starts with a short anthology about how two types of education affected his life.

There is no denying that a good education is a useful skill to have in the adult world. It definitely

helped Rose become a smarter, better person. However, Rose was not just another product of the

education system. His parents, who were Italian immigrants, never got the opportunities he did

ENG 111 8

when it came to schooling, so Rose’s early life was spent seeing relatives work in the service and

trade industries. He often watched how his mom waited tables and was fascinated by it: “I

couldn’t have put in words when I was growing up, but what I observed in my mother’s

restaurant defined the world of adults, a place where competence was synonymous with physical

work” (Rose 450). Although a formal schooling got Rose into a good position in a professional

career, he never forgot where he came from or how his mother always knew what to do while

working– a different kind of intelligence, one that required precise decisions, sense of time, and

plenty of experience. Rose uses his diner days as an opening to his article to not only display his

appreciation for people with service jobs, but to show that it led to his research with service

workers and discovering how exactly their minds worked.

Rose’s mom was able to memorize complex orders using memory tricks, negotiate with

the cook successfully, and talk with her family while knowing exactly how many refills of coffee

were needed around the restaurant. These are some of the few examples of the feats that Rose

remembers his mother doing. “Blue Collar Brilliance” is brimming with examples of not only his

mother but examples of his uncle Joe and the multiple people that Rose worked with. Since most

of his research in the workforce is experienced-based, Rose tries to introduce a window into the

workforce experience for the reader because schooling is not enough for the reader to

comprehend how challenging a service job can be: “A significant amount of teaching, often

informal and indirect, takes place at work” (Rose 455). To achieve this, he lets readers get a

glimpse of how the experience works through sensory nouns and verbs: “Much of the physical

work is social and interactive. Movers determining how to get an electric range own a flight of

stairs requires coordination, negotiation, planning, and the establishing of incremental goals

(Rose 455).” These examples allow readers to get absorbed into how multiple trade careers work

ENG 111 9

in a single sitting so they can get a better understanding about the hidden intelligence blue collar

workers have. While many see an oily mechanic fixing a screw, the mechanic is calculating how

tight the screws have to be so that they don’t fall off in the middle of the road; what type and size

of screw the car needs; and if that screw needs a special wrench or not.

Most people know that this kind of intelligence has a name: “street-smart.” Not

surprisingly, just like blue collar jobs, street smarts are underappreciated in the world of today.

Gerald Graff, a fellow intellectual and education reformer, sums up the situation perfectly:

“What a waste, we think, that one who is so intelligent about so many things in life seems unable

to apply that intelligence to academic work” (Graff 418). However, people with street smarts

excel at the high-paced, constantly changing environment of the workplace. In order to explain

how street-smarts tie into practical work, Rose goes all out academic on the cognitive demands

of the multiple jobs displayed throughout the article: “Carpenters have an eye for length, line,

and angle; hair stylists are attuned to shape, texture, and motion. Sensory data merge with

concept, as when an auto mechanic relies on sound, vibration, and even smell to understand what

cannot be observed” (Rose 455). Workers, Rose says, need to grasp time management, social

skills, immediate demands, self-control, technical skills, and multitasking all in a shorter amount

of time. In order for Rose’s own mother and uncle to succeed in their jobs, they needed to

understand people and how to get their messages across with complete clarity, something that

equates to a psychology or a public speaking class. There is no time to sit idly by and read a

production manual; hours of grueling practice are endured to make most of the worker’s every

move so that everything can be done perfectly and on time.

Through his research and past, Mike Rose has stressed the fact that the workplace,

whether in service or trade, is a living classroom that is frequently underestimated. Throughout

ENG 111 10

“Blue Collar Brilliance,” Rose breaks down multiple jobs analytically for the scholarly mind,

exposing the social, technical, and cognitive workings of multiple service jobs all with details fit

for the experience itself. While the scholar learns about something, the practical worker learns a

similar topic while doing another task in the process. Workers have the cognitive knowledge,

Rose explains, to do a multitude of tasks at the same time while honing their social skills to the

benefit of their services (Rose 455). The barista at the coffee shop may know how to make

twelve different kinds of espresso drinks without much thought. The boy mechanic can know

about the broken muffler just by hearing that sweet motor run. The factory workers know how to

organize themselves, boosting their production rates with their special knowledge of the

infrastructure and machines. People forget that most of the economy, and even the people

themselves, run on double-shot coffee, cars, and cheap, factory-produced goods. Mike Rose

brings up an important truth: some people may not be book-smart, but that does not mean that

they are necessarily stupid. Intelligence comes in multiple ways. At least, until the robots take

over.

ENG 111 11

Works Cited

Graff, Gerald. “Hidden Intellectualism.” The Norton Reader: An Anthology of Nonfiction, edited

by Melissa A. Goldthwaite et al., 14th ed., W. W. Norton, 2017, pp.418-22.

Kennedy, Emma. “Opinion: Blue Collar Workers Are Treated as Lesser Citizens.” The New

Political, 22 Mar. 2017, thenewpolitical.com/2017/03/21/opinion-blue-collar-workers-

reated-lesser-citizens. Accessed 28 Oct. 2018.

Rose, Michael. “Blue-Collar Brilliance.” The Norton Reader: An Anthology of Nonfiction, edited

by Melissa A. Goldthwaite et al., 14th ed., W. W. Norton, 2017, pp.449-56.

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ENGLISH ESSAY 300 WORDS. Write In Third-Person Perspective. Do Not Address The Reader, Except In The Call To Action.

December 15, 2023/in Uncategorized /by Daniel Jennings

Choose one of the following topics to write about:
1. Sightseeing in your city (or your favorite city to visit)
2. Party locations in your city
3. Your favorite store, business or brand
4. Your favorite film or book (avoid spoilers!)
Keep your submission between 200 and 300 words.
Some HTML coding is required in this sample. The specific HTML required will be listed in the following instructions. For help applying the HTML formatting, check out this video.
Begin with an appropriate title.
- Use HTML to format the title with H1 tags and italics.
Introduce the topic in no more than 100 words. This introduction should pique the reader’s interest so they’ll want to keep reading.
Continue with a meaningful subheading that refers to the next paragraph.
- Use HTML to format the subheading with H2 tags.
In the following paragraph, go into detail about one aspect of the topic you’ve chosen. This paragraph should demonstrate how well you can argue your points.
End your submission with a call to action that encourages the reader to check out the topic for themselves.
Use HTML strong tags to highlight keywords or important points in the text. Do not include more than 3 or 4 instances of bold text, and logically spread it throughout the article.

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DB 2 543

December 15, 2023/in Uncategorized /by Daniel Jennings

2 2 5

L e a r n i n g O b j e c t i v e s

C H A P T E R 9

A C H I E V I N G R E L I A B L E Q U A L I T Y A N D S A F E T Y

After reading this chapter, you will be able to

➤ explain the role of reliability science in the improvement of healthcare services,

➤ recognize how process reliability is measured and managed,

➤ identify strategies to increase the reliability of healthcare processes by improving

the effectiveness of people and the systems in which they work, and

➤ discuss how to measure the effectiveness of improvement actions and sustain

the gains.

➤ Catastrophic processes

➤ Human factors

➤ Noncatastrophic processes

➤ Reliability science

K e y w o r d S

Spath, Patrice. Introduction to Healthcare Quality Management, Third Edition : Third Edition, Health Administration Press, 2018. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/westernkentucky/detail.action?docID=5517319. Created from westernkentucky on 2021-02-15 13:07:15.

I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t2 2 6

E very year, healthcare organizations throughout the United States conduct hundreds of improvement projects following the models and using the tools you studied in the preceding chapters. With all of this activity, you might think the quality of healthcare

services is exemplary, with few inefficiencies and mistakes. Yet studies of healthcare perfor- mance continue to report high rates of error, overuse of services, and costly wastefulness (Agency for Healthcare Research and Quality 2016).

Why are many of the expected improvements not materializing? Does the fault lie with the improvement project models or tools? Do we need to conduct twice as many proj- ects and involve more frontline workers? Although a lack of significant progress is caused by many factors, one element that greatly contributes to quality problems is the design of work systems. As noted by Paul Batalden, MD, director of healthcare improvement leadership development at Dartmouth Medical School in Hanover, New Hampshire, “every system is perfectly designed to get the results it gets” (McInnis 2006, 32). If we want fundamentally different results in healthcare, we must use fundamentally different improvement strategies.

Regardless of which improvement model is used for a project, at some point actions or risk reduction strategies are designed. Often these interventions focus on creating new procedures and training people to do their job correctly. Too little attention is given to the work systems that give rise to inefficiencies and human errors. Bohmer (2010) proposes that the only realistic hope for substantially improving healthcare delivery is for the core processes to be revamped.

In this chapter, we introduce the systems approach to achieving safe and reliable healthcare. These techniques are based on reliability science, sometimes called human factors engineering, which originated in the US military during World War II (Wickens et al. 2012). The concepts are commonplace in other industries and should be applied when healthcare improvement teams reach the action planning phase of a project. By thinking differently about the changes needed to improve performance, project teams can have a significant and sustainable positive impact.

re l i a b l e pe r f o r m a n C e Performance reliability can be measured in various ways. The simplest way is to measure process output or outcomes. The number of actions that achieve the intended results are divided by the total number of actions taken. For instance, when you see your doctor, you expect her to have access to the results of your recently completed laboratory tests. The reliability of that process can be measured by gathering data on the occurrences of missing lab test results. If a clinic finds that 15 percent of outpatient appointments are affected by missing lab information, the process is said to have a failure rate of 15 percent and a reliability rate of 85 percent.

Reliability science

A discipline that

applies scientific

know-how to a process,

procedure, or health

service activity so

that it will perform its

intended function for

the required time under

commonly occurring

conditions.

C h a p t e r 9 : A c h i e v i n g R e l i a b l e Q u a l i t y a n d S a f e t y 2 2 7

You may not clearly understand the concept of reliability; however, when your automobile will not start, you clearly understand the concept of failure. You also learn the cost of failure when you have to pay a mechanic to restore your automobile to a reliable condition.

Human factors scientists and engineers have studied the interactions of people, technology, and policy across multiple industries for years. Knowledge gained from these studies allows us to predict the rate of failures based on the reliability rating of the process. For instance, if the clinic’s process of reporting lab results has an 85 percent reliability rating, the clinic physicians should expect miss- ing results for one or two of every ten patients who underwent recent laboratory tests. Exhibit 9.1 shows the expected failure rates for each level of reliability (Resar 2006).

The reliability of healthcare processes var- ies. Studies suggest that most US healthcare orga- nizations currently perform at the 90 percent level of reliability, meaning they have a failure rate of 1 in 10 (Nolan et al. 2004). Some hospital processes (e.g., hand hygiene, hand-off communications) fail 40 to 60 percent of the time (Bodenheimer 2008; Erasmus et al. 2010). One of the most reliable healthcare processes is giving patients compatible blood for a transfusion. Failures of this process are rare, with the reliability rate estimated to be 99.999 percent (Amalberti et al. 2005).

Human factors

“The environmental,

organizational and job

factors, and individual

characteristics which

influence behavior at

work” (Clinical Human

Factors Group 2016).

Reliability Level (%) Expected Failure Rate

Less than 80 Unpredictable, chaotic performance

80–90 1–2 failures out of 10 opportunities

95 Up to 5 failures per 100 opportunities

99.5 Up to 5 failures per 1,000 opportunities

99.99 Up to 5 failures per 10,000 opportunities

99.999 Up to 5 failures per 100,000 opportunities

99.9999 Up to 5 failures per 1,000,000 opportunities

exhibit 9.1 Process Reliability Levels and Expected Failure Rates

DID YOU KNOW??

• You have a 1 to 2 percent chance of dying accidentally for

every 10 mountains you climb in the Himalayas. The reliabil-

ity rating for this high-risk activity is 80 to 90 percent. Bun-

gee jumping has a similar risk of death.

• Automobile travel is fairly safe, with a reliability rating of

99.99 percent. The risk of a fatal accident is low—up to 5 for

every 10,000 times you ride in a car.

• The reliability of commercial aviation is better than 99.9999

percent, with an extremely low risk of a complete engine fail-

ure leading to loss of aircraft.

Source: Amalberti et al. (2005).

I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t2 2 8

i m p r o v i n g Q u a l i t y

Reliability ratings are important for healthcare quality improvement purposes. Reliability science has demonstrated that certain process improvements are more likely to create consistent quality. When improvement actions rely mostly on people’s vigilance and hard work to get things done correctly, the best level of reliability that can be achieved is 80 to 90 percent (Luria et al. 2006). On occasion, higher levels of reliability can be achieved, but they are not possible to sustain over time.

People often work in complex healthcare environments without carefully designed mistake-proofing infrastructures. For instance, hospital nurses are constantly interrupted as they carry out important patient care duties. In a review of several studies of nurse activities, the reported interruptions per hour ranged from 0.3 to 13.9 (Hopkinson and Jennings 2013). Healthcare professionals are able to cope with these situations and, most often, performance is not affected. However, people cannot be vigilant 100 percent of the time, and mistakes happen.

Exhibit 9.2 summarizes the types of actions necessary to achieve sustained reliable quality at different percentages (Amalberti et al. 2005). These actions, based on human factors and reliability science principles, should be considered in the design of actions intended to improve quality.

Not every healthcare process can be made highly reliable. Resources are insufficient, and not every process requires a high (99.5 percent or greater) level of reliability. For noncatastrophic processes, good outcomes depend on having at least 95 percent process reliability. For catastrophic processes, good outcomes depend on having 99.5 percent or better reliability. Improvement project teams should agree on the desired level of reliability and then implement actions that will achieve this level. For some healthcare processes, 80 to 90 percent reliability may be sufficient. Organizations might achieve better patient outcomes by bringing several chaotic processes to 90 percent reliability rather than concentrating on improving the reliability of just a few to 99.5 percent. This thinking coincides with the risk management concept of ALARP, which stands for “as low as reasonably practicable.” Deter- mining the extent to which workplace risks are controlled “involves weighing a risk against the trouble, time and money needed to control it” (Health and Safety Executive 2014).

The US Department of Veterans Affairs (VA) National Center for Patient Safety (2016) created an action categorization system on the basis of human factors science. These action categories are used by teams involved in root cause analyses and other patient safety improvement projects. Rather than divide improvement actions into levels of reliability, the actions are labeled as weak, intermediate, and strong. Studies at the VA have shown that when a strong action is developed and implemented, it is 2.5 times more likely to be effective at improving performance than are weak or intermediate actions (DeRosier, Taylor, and Bagian 2007). The types of actions that fall into the weak, intermediate, and strong categories are listed in exhibit 9.3.

Noncatastrophic

processes

Processes that do

not generally lead

to patient death or

severe injury within

hours of a failure

(e.g., hand hygiene,

administration of low-

risk medications).

Catastrophic processes

Processes with a high

likelihood of patient

death or severe injury

immediately or within

hours of a failure

(e.g., identification of

correct surgery site,

administration of

compatible blood for a

transfusion).

C h a p t e r 9 : A c h i e v i n g R e l i a b l e Q u a l i t y a n d S a f e t y 2 2 9

Reliability Level (%) Actions

Less than 80 Primarily rely on qualified people doing what they believe is the right thing

80–90 Implement basic failure prevention strategies, such as the following: • Standard protocols/procedures/order sheets • Personal checklists • Common equipment • Feedback on compliance • Awareness and training

95 Implement sophisticated failure prevention and basic failure identification and mitigation strategies, such as the following: • Build decision aids and reminders into the system. • Set the desired action as the default (based on scientific

evidence). • Account for and take advantage of habits and patterns in the

process design. • Specify process risks, and articulate actions for reducing risks. • Take advantage of scheduling. • Use redundant processes. • Operate independent backups. • Measure and provide feedback on compliance with process

specifications.

99.5 Gather information to understand which failures are occurring, how often they occur, and why they occur. Then redesign the system to reduce these failures using sophisticated failure prevention, identification, and mitigation strategies: • Design the system to prevent the failure, making sure the

steps in the process act independently of each other so failures can be identified and corrected.

• Design procedures and relationships to make failures visible when they do occur so they may be intercepted before causing harm.

• Design procedures and build capabilities for fixing failures when they are identified or mitigating the harm caused by failures when they are not detected and intercepted.

Better than 99.5 Moving beyond 99.5% requires technology and advanced system design that require significant resource investments.

Source: Adapted from Nolan et al. (2004).

exhibit 9.2 Actions Necessary to Achieve Reliability Levels

I n t r o d u c t i o n t o H e a l t h c a r e Q u a l i t y M a n a g e m e n t2 3 0

Improvement teams frequently favor weak interventions over higher-level actions because weak actions are lower risk and easier to create and implement. Staff training and distribution of memos telling everyone to follow procedures can be accomplished fairly easily. Unfortunately, such actions by themselves rarely have a lasting impact (Williams and Bagian 2014). Training can be made stronger by combining it with periodic competency assessments involving random observation by management. People newly trained in a procedure are more likely to follow it if they know they will be occasionally and randomly observed (Bernstein et al. 2016).

ap p ly i n g re l i a b i l i t y pr i n C i p l e S When actions based on reliability principles are not incorporated into the design of health- care improvement initiatives, the project goals are less likely to be achieved. Consider

Strength of Improvement Action Example of Action

Weak • Double-checks • Warnings and labels • New procedure/policy • Memos • Training • Additional study/analysis

Intermediate • Checklist/cognitive aid • Increase in staffing/decrease in workload • Redundancy • Enhanced communication (e.g., read back) • Software enhancements/modifications • Elimination of look-alikes and sound-alikes • Elimination/reduction of distractions (e.g., sterile

medical environment)

Strong • Architectural/physical plant changes • Tangible involvement and action by leadership in

support of patient safety • Simplified process, with unnecessary steps removed • Standardized equipment, process, or care map • New-device usability testing before purchasing • Engineering control or interlock (forcing functions)

Source: Reprinted from National Center for Patient Safety, US Department of Veterans Affairs, “Root Cause Analysis.” Retrieved from www.patientsafety.va.gov/professionals/onthejob/rca.asp. Copyright © 2016.

exhibit 9.3 Strength of Various

Improvement Actions

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what happened in the following case study. An improvement team met for several weeks to design and implement actions aimed at reducing the incidence of heel pressure ulcers (skin breakdowns) among hospitalized patients.

C a S e S t u d y

Many patients in the hospital were developing heel ulcerations. More than 13 percent of patients aged 18 or older developed a heel ulcer within four days of admission. This rate was higher than the national average, so an improvement team was formed with representatives from nursing, physical therapy, and wound care services to reduce the incidence of heel ulcers by 50 percent within one year. The team evaluated current practices and implemented the following stepwise actions to improve the process:

1. Nurses were trained to use an assessment scoring system to identify patients at risk of heel ulcerations. A poster board showing assessment instructions was made available for five days in each nursing unit.

2. After reviewing the training material, nurses took a test to determine their proficiency in assessing a patient’s heel ulcer risk. A score of 90 percent was required to pass the test.

3. Once all nurses had taken and passed the test, a new protocol was implemented that required use of the risk-assessment scoring system at the time of a patient’s admission, 48 hours after admission, and whenever a significant change was seen in a patient’s condition.

4. The hospital’s computerized health record system was modified so nurses could add the patient’s ulcer risk score into the patient’s record at the required intervals.

5. Patients at moderate or high risk of a heel ulcer were started on a protocol of ulcer prevention that included application of a thin dressing or heel protectors on reddened areas and elevation of the patient’s heels with pillows.

One year after the actions were completed, the incidence of hospital-acquired heel pressure ulcers had not significantly changed. An analysis of current practices found that staff nurses were not consistently completing the periodic risk assessments and that heel ulcer prevention interventions were not always employed. A lot of work had been done by the improvement team, the people who had created the training and post-training exam, and the people who had modified the computerized record system, yet no significant improvements occurred.

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Everyone involved in improvement projects wants performance to improve. But good intentions are not enough to ensure good outcomes. To achieve better performance that is reliable, human factors science must be taken into consideration when making changes.

C o n S i d e r t h e h u m a n f a C t o r S

Often, improvement initiatives fail because we expect people to perfectly execute their job responsibilities. Competence is important to an individual’s ability to do her job—you wouldn’t expect someone untrained in automobile repair to fix your car. But humans are not perfect, and there are no guarantees that mistakes will not be made. Interventions to improve performance are most successful when they address both the individuals doing the work and the way in which work gets done. For instance, the automobile mechanic must be adequately trained, have the right tools, and be provided a tolerable work environment. When healthcare improvement teams reach the action-planning phase, they must consider the human aspects that cause inconsistent performance and design systems that promote reliable quality.

Strong and effective systems make people more effective than they might be without such systems. Changes in procedures, rules, workflow, and automation; the introduction of new technology and equipment; and other system changes help to make people effective. In addition, strong and effective people make systems more effective. Rather than blaming and shaming people for not doing their job, seek to develop and enhance the competencies and skills of people in the system and ensure their needs are met. When introducing workflow changes, automation, new roles, and other interventions designed to improve performance, consider the needs of the people involved and how they will be affected. Organizations often fail in this regard by making the following mistakes (Spath 2015):

◆ Creating additional work for fewer people

◆ Removing people from roles in which they were comfortable

◆ Placing people in unfamiliar new roles as if they were interchangeable parts

◆ Not involving or consulting with the people affected by decisions but instead making assumptions about what is “good for them”

When working in complex and sometimes fast-moving healthcare environments, people can become overwhelmed with tasks, potentially causing cognitive overload—a situ- ation in which the demands of the job exceed the individual’s ability to mentally process all the information encountered regarding a situation (Ternov 2011). To ensure people are as effective as possible in their job, cognitive overload must be minimized. Critical concept 9.1 shows how to do this.

C h a p t e r 9 : A c h i e v i n g R e l i a b l e Q u a l i t y a n d S a f e t y 2 3 3

t e S t r e d e S i g n e d p r o C e S S e S

Changes to processes are often implemented without a clear understanding of how the change affects other parts of the system—the people, other processes, and services. Testing the impact of redesigned processes on performance is a crucial step in all the improvement models described in chapter 5. One way to assess improvements is to test process changes, before they are implemented, on a small subset of activities or patients (usually five to ten individuals). If the changes achieve the intended goals, they can be applied to all activities or patients. Quantitative and qualitative data should be collected during the pilot phase of a process change. This information helps the project team see the impact changes will

CRITICAL CONCEPT 9.1 Steps to Reduce Cognitive Overload on People!

• Limit or discourage people from working when they are physically ill or under psy-

chological duress.

• Be sure people are physically and psychologically fit for the tasks that need to be

completed.

• Provide people with adequate breaks away from their job; breaks should not be op-

tional.

• Add technologies that reduce reliance on memory, and insist that the technology

be used as designed (e.g., barcoded patient identification systems, monitoring

systems).

• Rotate tasks in a department when possible; when people do the same task all the

time, they can become complacent and experience the effects of mental underload.

• Monitor people for excessive fatigue; a lack of adequate rest reduces productivity

and efficiency.

• Place limitations on employee overtime, and provide adequate off-work intervals

between shifts.

• Provide team training, including the use of simulation methods.

Source: Adapted from Kochar and Connelly (2013); Patel and Buchman (2016); Vincent and Amalberti (2016).

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have on the people doing the work as well as on related activities and systems. It also can convince others of the value of adopting the changes organization-wide.

Testing does not end at the pilot phase. After changes have been implemented for a short time, the team must determine how well they are working.

a C h i e v e 80 t o 90 p e r C e n t r e l i a b i l i t y

To consistently reach 80 to 90 percent work system reliability, the improvement team must create a specific process and use staff education and vigilance to achieve standardization. The attempt at reducing heel pressure ulcers described in the case study earlier in this chapter lacked an important component: vigilance. Specific processes were designed to assess a patient’s risk of a heel ulcer and to prevent one from developing, and staff was educated in these processes. But management exercised no ongoing oversight to determine if nurses were following the processes, and no actions were taken for noncompliance. Without vigilance, compliance slid, and the failure rate often exceeded 20 percent.

Standardization and vigilance are necessary to reach sustained 80 to 90 percent reliability. These contributors to quality can be instituted by creating defined protocols, requiring the use of common equipment or supplies, creating checklists that remind people what needs to be done, and following other methods for reducing process variation. Many of these techniques are the same strategies used during a Lean project to eliminate waste and improve process efficiencies (Zidel 2012).

Process standardization also improves patient safety. According to Bagian and colleagues (2011), local patient safety managers in VA facilities rated process standard- ization as one of the best interventions for achieving good results. Other actions rated as leading to much better results included those that improve the communication process between clinicians and those that enhance the computerized medical record through software upgrades.

If an improvement team has determined that 80 to 90 percent reliability is suffi- cient, it need not take further action other than periodic monitoring to ensure the failure rate does not increase. Exhibit 9.4 describes the steps that a rehabilitation facility took to reach 80 to 90 percent sustained compliance with hand-hygiene requirements. This level of reliability was the goal, so no further interventions were needed.

Additional improvement actions are necessary if a higher level of reliability is desired. They should not be taken, however, until a sustained level of 80 to 90 percent reliability has been achieved for at least six months (Baker, Crowe, and Lewis 2009). Adding improve- ment actions when a process is still unstable could further degrade reliability. The adverse effect of tampering was discussed in chapter 4.

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a C h i e v e 95 p e r C e n t r e l i a b i l i t y

Moving a work system from 80 to 90 percent reliability to 95 percent requires stronger interventions than have been adopted thus far. Some actions, such as building decision aids into the system, may be as straightforward as creating paper checklist reminders for people to use. Decision aids can also take the form of more sophisticated computerized feedback that alerts people to unusual clinical situations requiring attention.

Intermediate and strong actions needed to improve the reliability of a process to 95 percent are listed in exhibits 9.2 and 9.3. Often, a number of advanced failure prevention and failure identification and mitigation strategies are needed. For instance, the inpatient psychiatric unit at Sinai Hospital of Baltimore (2017) reduced the incidence of patient elopements (unauthorized absence without permission) from four attempted and actual elopements in 2013 to none in 2016. To achieve this improvement, the unit implemented several interventions throughout 2015 and 2016:

◆ Provide staff education to improve awareness and increase staff vigilance

◆ Add more security cameras in the unit

Improvement Action Measurement Results

1. Mandatory hand-hygiene and infection-control training for all patient care staff

40% compliance

2. “Clean Your Hands” posters displayed in units; weekly observation reviews by infection control team, with immediate feedback for noncompliance

Up to 60% compliance

3. Hand-hygiene process standardized using “Five Key Moments for Hand Hygiene” and staff educated in process; data gathered to better understand the causes of noncompliance so that process can be changed to prevent these failures

Up to 70% compliance

4. “Five Key Moments” posters displayed in units and patient rooms; hand-hygiene reminders included in shift change discussions and during patient bed rounds; ongoing weekly observation reviews by hand- hygiene champions, with nonconfrontational feedback for noncompliance; continued evaluation of causes of noncompliance and changes made to prevent failures

Sustained 80–90% compliance

exhibit 9.4 Rehabilitation Facility Hand- Hygiene Improvement Project

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◆ Keep patients in hospital garments for 24 hours after arrival in the unit

◆ Limit the number of outside staff with access to the locked unit

◆ Escort ancillary hospital staff pushing carts (food and linen) to the unit exit door

◆ Dress patients at risk for elopement in green gowns and green socks

◆ Place black-out tape over the five-second flashing green light on the exit door badge scanner

◆ Install safety signs to direct patients to the day area and away from high-risk elopement areas

◆ Add a “panic button” to the staff communication devices to allow for immediate and simultaneous elopement alerts

Exhibit 9.5 shows intermediate and strong actions taken by a hospital to improve the reliability of the intravenous (IV) medication and solution administration process. These actions resulted in sustained 95 percent reliability for many of the process steps. Of course, the interventions differ in their power to effect changes. Some, such as automated functions that prevent IV pumps from being incorrectly programmed, are very strong in preventing failures. Other interventions, such as labels on the IV bags, are less likely to reduce failures. An important step in any improvement project is to closely monitor the effectiveness and impact of action plans and make adjustments as needed.

a C h i e v e 99.5 p e r C e n t o r b e t t e r r e l i a b i l i t y

Some healthcare processes should function at 99.5 percent reliability or better because failures within them are likely catastrophic for patients. To achieve 99.5 percent performance or greater requires identifying failures, determining how often they occur, and understanding why they occur.

Specifically, getting to 99.5 percent reliability requires three essential steps. First, process failures must be closely monitored. Second, targeted interventions must be designed and tested until the desired level of reliability is achieved and maintained. For example, a large ambulatory health center in the South implemented several process changes to ensure patients with diabetes have regular body mass index (BMI) measurements (Baker, Crowe, and Lewis 2009). In addition to educating staff on the importance of obtaining a BMI at every patient visit, BMI was made a data element on the clinic’s standardized flow sheet that serves as the front page of the record. A care manager reviews patient records the day before a visit to determine if BMI is entered into the electronic record, and job descriptions for all patient care staff were updated to include the task of ensuring BMI documentation

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Type of Action Intervention

Standardization is pervasive

• Reduce the variety of IV solutions available as floor stock to those most frequently used

• Use only standard concentrations of IV solutions • Make only one kind of IV medication pump in each class

available in the hospital • Develop and implement standard IV physician orders

Decision aids and reminders are built into the system

• Label all IV solutions that do not come from the pharmacy with a tag displaying the nurse’s name, date, name of solution, and rate of administration

• Place on each IV bag a drug-specific label containing flow rate calculations

• Program standard IV orders into the computerized order entry system

The desired action is the default

• Use IV pumps with forcing functions to prevent programming errors

Habits and patterns are studied and used in the design

• Change the arrangement of the medication access control device so only one injection is available per drawer

Process risks are specified, and actions for reducing risks are articulated

• Include discussion of risks and interventions in the annual staff competency assessment process to reduce these risks

Scheduling is used to advantage

• At change of shift, double-check all potentially hazardous IVs (medications, pump settings, and IV tubing) for failure

Redundant processes are in place

• Place on each IV bag a drug-specific label containing flow rate calculations

Independent backup is in place

• Have two nurses independently double-check all IV medications, pump settings, and IV tubing before administration and before patient transfer to another location

Compliance is measured and results are shared

• Gather data on compliance with the new process and the number of incidents involving IV medication and IV solutions; regularly evaluate results and share with everyone involved in the process

exhibit 9.5 Examples of Interventions That Improved Reliability of Administration of IV Medications and Solutions

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at every visit. After experiencing negative reactions from some patients when asked to be weighed, the clinic revised its diabetic education materials with input from patients. The percentage of patients with diabetes with a completed BMI improved from less than 20 percent to 100 percent.

Third, once sustained reliability (99.5 percent or better) is achieved, performance must be regularly reviewed and feedback provided to the people doing the work. Every

failure should be examined, and the information obtained should be used to redesign the process or create ways for staff to better identify and cor- rect failures quickly or to lessen the effects of the failures.

In some situations, the healthcare organiza- tion may seek to improve reliability to 99.9 percent or better. Achieving such a high level of reliability requires more than human labor. Technology and possibly architectural changes are needed. Anesthe- sia administration, once thought to cause 1 to 2 deaths in every 10,000 patients receiving anesthe- sia, is now considered to be one of the most reliable processes occurring in healthcare delivery (Stoelt- ing 2017). A host of changes to anesthesia admin- istration, based on an understanding of human factors principles, were initiated throughout the United States in the 1970s. Reaching the current high level of reliability required the adoption of

important safety technology (pulse oximetry, capnography, audible physiologic alarms, electronic health records) as well as improvements in the culture of safety. Overall, the combined effect of all the initiatives has been a 10- to 20-fold reduction in mortality and catastrophic morbidity for healthy patients undergoing routine anesthesia (Stoelting 2017).

mo n i t o r i n g pe r f o r m a n C e Designing process changes on the basis of reliability science is the starting point to achieving consistently high quality. The next step is to make the changes. Once the improvement team has developed action plans, leadership oversight will ensure the actions are implemented as intended. Researchers studying the implementation of corrective measures following root cause analyses found that healthcare organizations never fully implemented up to 55 percent of the proposed actions (Peerally et al. 2016).

The organization’s progress in implementing action plans must be tracked and leaders kept informed of outstanding and completed action items. Exhibit 9.6 is an excerpt from a monthly report on the status of improvement actions provided to hospital leaders. When

LEARNING POINT Reaching 95 Percent or Better Process Reliability*

Reaching 95 percent or better process reliability involves four

main steps:

1. Agree on a measure for assessing reliability.

2. Measure how often accuracy is achieved according to the

agreed-on measure, thereby establishing a baseline against

which to compare results of the initiative.

3. Establish reliability goals for the measure.

4. Make stepwise improvements and measure success.

Source: Dlugacz and Spath (2011).

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delays are unacceptable, senior leaders often need to intervene to clear away implementa- tion barriers. In chapter 12, we discuss the leadership structure necessary to support quality management activities, including the role of the organization’s governing board and quality oversight groups in monitoring performance.

m e a S u r e e f f e C t i v e n e S S

Improvement goals are set at the start of an improvement project. Clearly documented goals help frame the improvement initiative. The project goals guide decisions about what needs to be changed in the process and how best to accomplish the changes. Once action plans

Date of Report: ____________________________________________

Current Status Project Description Actions Responsible Party Actions to Date

Needs attention

Reduce delays in start times for interventional radiology procedures

1. Revise the patient scheduling procedure

2. Publish an article about new policy in medical staff newsletter

3. Revise the scheduling software to accommodate new policy

4. Conduct monitoring by radiology department for compliance with new policy

1. Imaging director

2. Medical staff services office

3. Imaging director and software vendor

4. Imaging director

1. Done

2. Done

3. Vendor has repeatedly canceled on-site visit for software upgrade

4. Radiology department unable to start new procedure due to software upgrade delay

In progress Improve timeliness of electrocardiogram (EKG) interpretations

1. Standardize the EKG interpretation process

2. Modify transmission process at off-site locations

3. Obtain software upgrade to enable results tracking

1. Vice president of medical affairs

2. Diagnostic center managers

3. Managers of noninvasive cardiology and information technology departments

1. Done

2. Done

3. Funds for software in next year’s capital budget

exhibit 9.6 Improvement Action Tracking Log

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have been implemented, evaluate whether goals have been achieved. Regardless of what improve- ment model is used to execute the project, it will include a step in which the effectiveness of action plans is measured.

Action plan effectiveness can be determined using process or outcome measures. Recall from chapter 3 that process measures are data describing how services are delivered, and outcome measures are data describing the results of healthcare ser- vices. Exhibit 9.7 is a description of an improve- ment project undertaken in a multiclinic primary care organization to improve the use of preventive care screenings. Several actions were taken, and three measures were used to evaluate the success of the actions.

Chapter 3 discusses data collection sys- tems for gathering performance measurement information. Similar data collection systems must be enacted to measure the effectiveness of action plans. Useful and accurate performance information is needed to judge the success of action plans.

A question that often arises during discus- sions of how to measure the success of improve- ment actions is, How long must we continue to gather and report measurement data? Ideally, all of the following criteria should be met to con-

clude that successful corrective action plan implementation has been achieved (Minnesota Department of Health 2015):

◆ Data for the process measure were monitored over time.

◆ The goal was attained (process and outcome).

◆ You are confident that the change is permanent.

◆ The event is not repeated (if improvements were made to prevent another adverse event).

LEARNING POINT Measuring Action Plan Effectiveness*

Consider the following questions when developing measures to

evaluate the success of improvement actions:

1. How will you know the action has been effective in improving

performance?

2. What will you evaluate to determine if the process is more

reliable?

3. Do you have any data that can be used for before-and-after

comparisons?

4. How often will you measure performance (by shift, daily,

weekly, biweekly, monthly, other)?

5. How will data be gathered, and by whom?

6. How long will you continue to measure performance?

7. How often will performance results be reported, and to

whom?

8. Once measurement data substantiate that performance

goals are met, how often will you measure to ensure im-

proved performance is sustained?

Source: Adapted from Bagian et al. (2011).

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re a l i z i n g Su S ta i n e d im p r o v e m e n t S Once the desired level of reliable quality has been reached, the problems affecting undesir- able performance must stay fixed. “I thought we solved that problem already” is an utter- ance often heard in healthcare organizations. Financial and human resources are constantly expended on improvement projects and system redesign, yet familiar problems may creep back in to disrupt the performance of key processes. Managers trying to improve perfor- mance sometimes make mistakes that could have been avoided with forethought.

Improvement Project Goal: Increase rates of preventive care screening services Improvement Actions: 1. Telephone patients to remind them to come to the clinic for needed preventive care

screening. 2. Design a preventive care services summary in patient electronic records to

document needed preventive screening, date of patient contact, and date of completion.

3. Educate staff in preventive service requirements and how to use the summary in patient records.

4. Change the workflow to include having medical assistants or nurses prepare paperwork for preventive screenings before a patient’s visit and give to the provider at the time of the visit.

How Effectiveness of Actions Will Be Measured:

Measure Data Collection Method Goal

Percentage of patients needing preventive screenings who are contacted by phone

Quarterly query of database of patients needing screenings to determine if patient was contacted

Sustained 95 percent

Percentage of patients needing preventive screenings who receive them as required

Quarterly query of preventive care services summary database

Sustained 95 percent

Number of patients who refuse preventive screenings after discussion with provider

Quarterly query of preventive care services summary database

No more than 5 percent per quarter

exhibit 9.7 Improvement Project Measures of Action Plan Effectiveness

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C h a n g e b e h av i o r S

When process improvements come undone, the cause often can be traced back to the attitudes or behaviors of the people doing the work—behaviors that should have been modified but were not. Process improvement efforts tend to focus on standardizing and error-proofing work steps and sometimes overlook the human part of the process. For instance, nurses in a hospital that implemented a barcoded patient identification system to reduce medication errors found the process too cumbersome and began to take shortcuts (Koppel et al. 2008). The nurses made duplicate copies of patient wristbands so they could check the barcodes at the nursing station rather than in patient rooms. This shortcut sig- nificantly raised the potential for medication errors. Understanding what causes shortcuts is at the heart of knowing how to modify attitudes and behaviors. This is just as important as creating a more efficient process. Otherwise, people will lapse into the old way of doing things, and the new process will have no chance of becoming a habit.

Why don’t people adopt desired process changes? Five main factors that affect per- formance are listed in exhibit 9.8.

Performance Factor Possible Interventions

Expectations Do people know what they are supposed to do?

• Provide clear performance standards and job descriptions.

• Create channels to communicate job responsibilities.

Feedback Do people know how well they are doing?

• Offer timely information about people’s performance.

• Use mistakes as learning opportunities.

Physical environment Does the work environment help or hinder performance?

• Make sure people are able to see, hear, touch, and feel what is necessary to do the job.

• Correct problems causing environment, supply, or equipment complaints.

Motivation Do people have a reason to perform as they are asked to perform? Does anyone notice?

• Frequently provide reinforcement to people while they are learning new tasks.

• Apply consequences (positive or negative) to change behaviors toward the desired direction.

Required skills and knowledge Do people know how to do the task?

• Ensure people have the skills needed to perform the work.

• Provide access to learning opportunities.

exhibit 9.8 Performance Factors and

Possible Interventions

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Interventions to achieve compliance with process changes vary according to the performance issue, but the cause of failures must be understood before action is taken to correct them.

d o n ’ t o v e r l o o K e d u C at i o n

Knowledge, diligence, effort, focus, resources, and effective leadership are all essential to the achievement of performance improvement goals. Leaders would be unwise to announce improvement priorities and then expect the improvements to automatically materialize. This approach does not work. Just as cheerleading does not improve a football team’s chances of winning, announcements from leadership alone do not create reliable quality. Project teams need encouragement from leaders, but everyone involved in process improvement also must be able to use basic quality tools and techniques such as those covered in this text.

Only recently has more attention been given to securing reliable healthcare quality through the application of human factors principles and reliability science. Rather than tinker with work systems and hope for the best, some healthcare organizations are applying improvement strategies that have been used successfully for years in other industries. High-reliability industries, such as aviation, air traffic control, and nuclear power, have long recognized that relying on human perfection to prevent accidents is a fallacy. These industries conduct training, enforce rules, and expect their high standards to be met, but they do not rely on people being perfect to prevent accidents. They look to their systems, as should healthcare organizations (Ghaferi et al. 2016).

Human factors and reliability design concepts should be required for all healthcare improvement projects. To reach higher levels of reliable performance, systems and processes must be designed to be more resistant to failure. Situations or factors likely to give rise to human error must be identified and process changes made to reduce the occurrence of failure or to minimize the impact of any errors on health outcomes. Efforts to catch human errors before they occur or to block them from causing harm are ultimately more fruitful than those seeking to somehow create flawless people.

The application of human factors principles and reliability science is long overdue in healthcare. As noted by Deming (1986), one of the founders of the contemporary quality movement, “It is not enough to do your best; you must know what to do, and then do your best.”

C o n C l u S i o n

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1. What does reliability mean to you? In your experience, what healthcare process have you found to be reliable? What process have you found to be unreliable? Explain what is different about the reliable process versus the unreliable process.

2. Consider the failed improvement project in this chapter’s case study when answering the following questions:

a. What process changes could be implemented to achieve 80 to 90 percent reliability in preventing and managing heel ulcerations?

b. What process changes could be implemented to reach 95 percent reliability in preventing and managing heel ulcerations?

c. If process changes are made to achieve 80 to 90 percent reliability, how would you measure the effectiveness of these changes?

d. If process changes are made to achieve 95 percent reliability, how would you measure the effectiveness of these changes?

• Agency for Healthcare Research and Quality (AHRQ) Innovations Exchange www.innovations.ahrq.gov

• AHRQ, Becoming a High Reliability Organization: Operational Advice for Hospital Leaders (April 2008) https://archive.ahrq.gov/professionals/quality-patient-safety/quality-resources/ tools/hroadvice/hroadvice.pdf

• AHRQ Comprehensive Unit-Based Safety Programs (CUSP) www.ahrq.gov/cusptoolkit/

• AHRQ Patient Safety Network: High Reliability https://psnet.ahrq.gov/primers/primer/31/high-reliability

• American Hospital Association, Hospitals in Pursuit of Excellence www.hpoe.org

• Clinical Human Factors Group http://chfg.org

• The Dartmouth Institute Microsystem Academy www.clinicalmicrosystem.org

f o r d i S C u S S i o n

w e b S i t e S

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• Grout, J. R. 2007. Mistake-Proofing the Design of Health Care Processes. AHRQ Publication No. 07-0020. Rockville, MD: Agency for Healthcare Research and Quality. https://archive.ahrq.gov/professionals/quality-patient-safety/patient-safety- resources/resources/mistakeproof/

• Healthcare Communities www.healthcarecommunities.org

• High Reliability Organizing http://high-reliability.org

• Home Health Quality Improvement www.homehealthquality.org

• Institute for Healthcare Improvement (IHI), “How to Improve” resources www.ihi.org/knowledge

• IHI, Improving the Reliability of Health Care. 2004. www.ihi.org/education/IHIOpenSchool/Courses/Documents/ CourseraDocuments/08_ReliabilityWhitePaper2004revJune06.pdf

• Massachusetts Coalition for the Prevention of Medical Errors www.macoalition.org/

• Medical Group Management Association. High Reliability Organization in the Healthcare Industry: A Model for Excellence, Innovation, and Sustainability. Focus paper. www.mgma.com/practice-resources/articles/fellow-papers/2016/high-reliability- organization-in-the-healthcare-industry-a-model-for-excellence-innovation-and-sus

• Project Re-engineered Discharge, hospital discharge research from Boston University Medical Center www.bu.edu/fammed/projectred/index.html

• Society of Hospital Medicine’s BOOSTing Care Transitions www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/CT_Home.cfm

Agency for Healthcare Research and Quality (AHRQ). 2016. 2015 National Healthcare Qual-

ity and Disparities Report and 5th Anniversary Update on the National Quality Strategy.

Rockville, MD: Agency for Healthcare Research and Quality.

Amalberti, R., Y. Auroy, D. Berwick, and P. Barach. 2005. “Five System Barriers to Achieving

Ultrasafe Health Care.” Annals of Internal Medicine 142 (9): 756–64.

r e f e r e n C e S

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Bagian, J. P., B. J. King, P. D. Mills, and S. D. McKnight. 2011. “Improving RCA Performance:

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BIO105

December 15, 2023/in Uncategorized /by Daniel Jennings

Protista

PRE-LAB QUESTIONS

1. Describe the three modes of locomotion found in protists.

2. Why are slime-molds considered “fungi-like protists” and not true fungi?

3. Why do you think so much attention is paid to the informal group protozoa by the medical research community?

Protista

EXPERIMENT 1: VIEWING PRESERVED SPECIES OF PROTISTS

Post-Lab Questions

1. Draw each organism from Figures 6 and 7 in the space provided below and label the major structures.

2. Answer the following questions:

a. What type of locomotion do you think each protist employs?

Figure 6:

Figure 7:

3. What advantage do you think a protist would gain by being autotrophic, heterotrophic, or mixotrophic?

Reflection (Discuss what you have learned by doing this experiment. How have your ideas changed? Do you have any new questions? What connections did you make between the lab and lecture?):

Protista

EXPERIMENT 2: VIEWING LIVE SPECIMENS

Post-Lab Questions

1. In the space provided below, draw the various members of the protist kingdom that you were able to observe. Next to each drawing, describe the speed and type of locomotion you observed.

2. Did you notice a difference in the protists when the slowing agent was used? Which members were you able to see more clearly? Were there species that were still moving too fast to see clearly? Could you identify any species specifically? Do any of them look similar to specimens you observed in the first lab?

Reflection (Discuss what you have learned by doing this experiment. How have your ideas changed? Do you have any new questions? What connections did you make between the lab and lecture?):

Pre-Lab Questions
Experiment 1: Viewing Preserved Species of Protists
- Post-Lab Questions
Experiment 2: Viewing Live Specimens
- Post-Lab Questions

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Microbes Everywhere Experiment

December 15, 2023/in Uncategorized /by Daniel Jennings

Home >Homework Answsers >Biology homework help

EXPERIMENT: Microbes Everywhere

PHOTOS – Include two digital photos with your lab report, either as separate attachments to an e-mail or paste into your document.

1. 1. Photo #1 – Take a photo of the six nutrient agar tubes AFTER they have been growing for at least two days. Lay them out so that it might be possible to get close enough to see some growth.

1. 2.Photo #2 – Take a photo of the slides you are treating with the gram stain, at some point during the procedure. (Preferably while you are flooding them with one of the stains and waiting.)

Exercise 1 – Finding Microbes:

2. Select six sources from your prioritized list that are from different areas of your home. Set up a data table similar to the one shown below to number your microbes and record information and observations about them for Exercise 1 and Exercise 2 activities.

Location Of Microbes	Colony Growth Notes….
#	Description	Temp	Shape	Color	Size	Type	Observations
1
2
3
4
5
6

7. 7. Use the hand magnifying lens to observe the growths of colonies within the tubes. Note their shape, size, color, and anything else distinguishing. Bacteria will grow in small circular colonies, whereas molds will spread out more and may look fuzzy. Yeasts tend to grow initially in tight, compact colonies and their color is somewhat darker than that of bacteria. Record what you see in the data table. Draw what you see for each. Try to deduce the types of microbes each cultured colony contains: bacteria, mold, or yeast. Some cultures may contain more than one type of microbe.

7. 8. If some of the cultures are not yet well developed let all of the cultures continue to incubate for up to three additional days until you see visible growth in them all. Record final observations for each tube.

Questions:

A. A. From which samples did you observe the most and least microbial growth?

A. B. Why do you think there were differences in the number and types of microbes at the different sampling sites?

A. C. Did microbes from warmer or cooler sites multiply faster? Hypothesize why.

A. D. How could the information gained in this experiment be useful in your home?

Exercise 2 – A Closer Look

Location Of Microbes	Gram Stain Notes………
#	Description	Temp	Shape	Color	Size	Type	Observations
1
2
3
4
5
6

Examine the slides under your microscope. Describe and draw what you see.

Questions:

A. A. Was the structure or arrangement of the colonies of microorganisms different among what you identified as bacteria versus yeast versus mold?

A. B. Four slides are, of course, a very small sample, but regardless of this limitation, what can you hypothesize about differences in the microbe growth patterns? Does your hypothesis match the descriptions at the beginning of the experiment?

A. C. Were you able to see any individual microorganisms? If so what would you guess they are (e.g., mold, yeast, etc.)?

A. D. Do any of the slides appear to have more than one type of microorganism? Did you determine this by physical appearance of the culture or by color of stain?

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Can You Halp Me With My Biology Test? Don’t Reply If You Are Not An Expert In Biology With Minimum MS Or Doctorate In Biology Please

December 15, 2023/in Uncategorized /by Daniel Jennings

Instructions

Select the correct answer for the 70 multiple-choice questions by highlighting the correct answer

1. Item 1

Enzymes:

A. Increase the energy of activation for a reaction, thus increasing the reaction rate.

B. Decrease the energy of activation for a reaction, thus decreasing the reaction rate.

C. Increase ΔG for a reaction, thus increasing the reaction rate.

D. Decreases the energy of activation for a reaction, thus increasing the reaction rate.

E. decrease ΔG for a reaction, thus increasing the reaction rate.

1. Item 2

Hemophilia is an X-linked recessive disorder involving blood clotting. If a Mr. Y, who is a hemophiliac, marries Mrs. Z, who is a carrier for hemophilia, and one of their daughters (Miss A, who is not a hemophiliac) marries a normal man (Mr. B), what is the probability that a grandson of Mr. Y and Mrs. Z is a hemophiliac?

A. 25% B. 50% C. 75% D. 100% E. Cannot be determined from the information given

1. Item 3

All of the following could cause increases in resting blood pressure EXCEPT:

A. increased Na+ reabsorption by the kidney.

B. increased heart rate.

C. decreased dehydration.

D. caffeine.

E. None of the above.

1. Item 4

The functions of the liver include all of the following EXCEPT:

A. formation of blood proteins.

B. regulation of glycogen metabolism.

C. secretion of bile.

D. storage of vitamins.

E. secretion of bicarbonate.

1. Item 5

Osteoblasts, osteoclasts, and osteocytes are the three cell types found in bone tissue. Osteoclasts are activated by:

A. low blood Ca2+ levels and high parathyroid hormone levels.

B. low blood Ca2+ levels and high calcitonin levels.

C. high blood Ca2+ levels and high calcitonin levels.

D. high blood Ca2+ levels and high vitamin D levels.

E. low blood Ca2+ levels and low parathyroid hormone levels.

1. Item 6

Which hormone binds to a receptor on the cell surface?

A. Aldosterone

B. Progesterone

C. Cortisol

D. Adrenaline

E. Testosterone

1. Item 7

Which of the following RNA sequences would be transcribed if the sequence of the DNA coding strand were TATTGCATCAA?

A. UAUUGCAUCAA

B. AUAACGUAGUU

C. TTGUTGCUUTU

D. AUAAGCAUCAA

E. UUGAUCGUUAU

1. Item 8

The pentose phosphate pathway is involved in all of the following EXCEPT:

A. eliminating reactive oxygen species.

B. producing nucleotides.

C. facilitating fatty acid synthesis.

D. forming NADH.

E. generating ribose-5-phosphate.

1. Item 9

When blood pressure is low, the rate of blood filtration drops. The kidney secretes renin to help compensate. The direct effect that renin has in the body is to:

A. generally constrict arterioles to increase peripheral resistance.

B. convert the blood protein angiotensinogen into angiotensin I.

C. convert angiotensin I into angiotensin II, a powerful vasoconstrictor.

D. dilate the renal artery.

E. dilate the glomerular capillaries.

1. Item 10

In designing antibiotics to treat infections caused by facultative anaerobic bacteria in humans, the targets which would be most attractive are inhibitors of bacterial:

A. mRNA splicing.

B. electron transport.

C. poly-A addition for mRNAs.

D. transcription.

E. None of the above.

1. Item 11

A double homozygous dominant rabbit with bent ears and big feet is crossed with a double homozygous recessive rabbit with straight ears and small feet. One of the F1s is backcrossed to the double homozygous recessive parent producing an F2 generation with the following ratios of phenotypes: 15 rabbits with bent ears and big feet, 15 rabbits with straight ears and small feet, 5 rabbits with bent ears and small feet, and 5 rabbits with straight ears and big feet. What is the recombination frequency between the gene for ear position and the gene for foot size?

A. 12.5%

B. 25%

C. 33.3%

D. 50%

E. 66.7%

1. Item 12

During muscle contraction, which regions of the sarcomere shorten?

I. A band II. I band III. H band

A. II only

B. I and II only

C. II and III only

D. I and III only

E. I, II, and III

1. Item 13

Which cells in the testes are responsible for secretion of testosterone?

A. Sustentacular (Sertoli) cells

B. Spermatogonia

C. Supporting cells

D. Interstitial (Leydig) cells

E. None of the above secrete testosterone.

1. Item 14

What is the primary effect of transposons?

A. Generate mutations and chromosomal rearrangements

B. Facilitate recombination during meiosis

C. Provide protection against integration of lysogenic viruses

D. Increase the affinity of RNA polymerase binding to a promoter

E. Conduct DNA replication proofreading

1. Item 15

The volume of air that remains in the lungs after a complete expiration is called the:

A. residual volume.

B. expiratory reserve volume.

C. functional residual capacity.

D. vital capacity.

E. tidal volume.

1. Item 16

All of the following are methods by which bacteria can achieve genetic diversity EXCEPT:

A. conjugation.

B. binary fission.

C. transformation.

D. transduction.

E. recombination.

1. Item 17

The dendrites of a single postsynaptic neuron often form synapses with axons of many different presynaptic neurons. The combined input of all the presynaptic neurons ultimately determines whether the postsynaptic neuron will fire an action potential or not. This is known as:

A. facilitation.

B. integration.

C. cooperativity.

D. temporal summation.

E. spatial summation.

1. Item 18

A hospital has possibly switched the babies of Couples X and Y. Their blood types are as follows:

Couple X: type A and type A Baby 1: type O

Couple Y: type AB and type O Baby 2: type B

Which baby belongs to which couple?

A. Both babies belong to Couple Y.

B. Baby 1 belongs to Couple Y and Baby 2 belongs to Couple X.

C. Baby 1 belongs to Couple X, but Baby 2 could belong to either couple.

D. Baby 1 belongs to Couple X and Baby 2 belongs to Couple Y.

E. Baby 2 belongs to Couple Y, but Baby 1 does not belong to either couple.

1. Item 19

If red blood cells are placed in pure water, which of the following would occur?

A. The cells would swell due to the high osmotic pressure of the water.

B. The cells would shrink due to the high osmotic pressure of the cells.

C. The cells would neither shrink nor swell because red blood cells are isotonic to water.

D. The cells would swell because they are hypotonic to the water.

E. None of the above would occur.

1. Item 20

The net products of glycolysis per glucose molecule are:

A. 4 ATP, 2 NADH, 2 pyruvate

B. 2 ATP, 2 NADH, 2 pyruvate

C. 2 ATP, 4 NADH, 2 lactate

D. 4 ATP, 4 NADH, 4 pyruvate

E. 2 ATP, 2 NADH, 2 lactate

1. Item 21

The hair cells on the basilar membrane represent which of the following receptor types?

A. Baroreceptor

B. Thermoreceptor

C. Mechanoreceptor

D. Chemoreceptor

E. Nociceptor

1. Item 22

Which of the following cells are produced by the first meiotic division of oogenesis?

A. Oogonium

B. Primary oocyte and first polar body

C. Secondary oocyte and first polar body

D. Secondary oocyte and second polar body

E. Mature ovum and second polar body

1. Item 23

Potassium moving down its concentration gradient through K+channels in the plasma membrane is an example of:

A. simple diffusion.

B. active transport.

C. exocytosis.

D. osmosis.

E. facilitated diffusion.

1. Item 24

All of the following can be observed during both meiosis and mitosis EXCEPT:

A. alignment of chromosomes on the metaphase plate.

B. separation of sister chromatids.

C. synapsis of homologous chromosomes.

D. cytokinesis.

E. dissolution of the nuclear membrane.

1. Item 25

The opening of which type of ion channel initiates an action potential?

A. Voltage-gated Na+

B. K+ leak

C. Voltage-gated K+

D. Voltage-gated Ca2+

E. Na+/K+ pump

1. Item 26

All of the following are true about Gram– bacteria EXCEPT:

A. they have thin cell walls.

B. they have an inner plasma membrane.

C. they stain a dark purple in Gram stain.

D. they are more resistant to antibiotics than Gram+ bacteria.

E. they have a layer of plasma membrane outside the cell wall.

1. Item 27

When measuring reaction velocity as a function of substrate concentration, a researcher usually keeps the concentration of enzyme at a constant level. What would happen if the enzyme concentration were NOT kept constant?

A. Vmax would remain constant, but V would change.

B. Vmax would remain constant, but Km would change.

C. Vmax would change, but Km would remain constant.

D. both Vmax and Km would change.

E. None of the above would necessarily occur.

1. Item 28

What role does p53, a typical product of a tumor suppressor gene, play in the cell?

A. Signal CD4 T cells to destroy a cell infected with a cancer-causing virus

B. Upregulate transcription of protooncogenes

C. Promote chemotaxis and diapedesis of the cell

D. Trigger apoptosis if abnormal cell growth cannot be halted

E. Stimulate production of additional mitochondria

1. Item 29

Which of the following correctly lists functions of the sympathetic nervous system?

A. Dilate pupils, reduce heart rate, increase blood pressure, inhibit GI tract

B. Increase heart rate, constrict pupils, decrease blood pressure, inhibit GI tract

C. Increase blood pressure, dilate pupils, dilate bronchial tubes, increase heart rate

D. Inhibit GI tract, increase heart rate, constrict bronchial tubes, increase blood pressure

E. Dilate bronchial tubes, stimulate GI tract, increase heart rate, constrict pupils

1. Item 30

All of the following statements about DNA replication are true EXCEPT:

A. it occurs in the 5′ to 3′ direction.

B. both new strands are replicated continuously along the parent strands.

C. prokaryotes use five different DNA polymerases.

D. it requires an RNA primer.

E. it is semiconservative.

1. Item 31

A virus infects a cell and immediately induces the cellular machinery to produce new viral particles. These new viruses exit the cell by budding through the cell membrane. Which of the following is true about this virus?

A. It is a plant virus involved in a lytic cycle.

B. It is a bacterial virus involved in a lysogenic cycle.

C. It is a plant virus involved in a productive cycle.

D. It is an animal virus involved in a lytic cycle.

E. It is an animal virus involved in a productive cycle.

1. Item 32

The structure that secretes progesterone during the menstrual cycle is the:

A. oocyte.

B. ovary.

C. developing follicle.

D. corpus luteum.

E. uterus.

1. Item 33

Which of the following lists organelles that have only a single membrane?

A. Nucleus, rough ER, mitochondria

B. Mitochondria, Golgi apparatus, rough ER C. Lysosome, Golgi apparatus, nucleus

D. Golgi apparatus, rough ER, lysosome

E. Mitochondria, lysosome, rough ER

1. Item 34

Which intermediate of cellular respiration is NOT part of gluconeogenesis?

A. Oxaloacetate

B. Phosphoenolpyruvate

C. Dihydroxyacetone-phosphate

D. Fructose-6-phosphate

E. Acetyl-CoA

1. Item 35

Which of the following sensory receptors are NOT mechanoreceptors?

A. Aortic baroreceptors

B. Hearing receptors in the Organ of Corti

C. Rods and cones

D. Pacinian corpuscles

E. Golgi tendon organs

1. Item 36

The hormone responsible for raising blood glucose levels between meals is:

A. glucagon.

B. insulin.

C. epinephrine.

D. ACTH.

E. none of the above.

1. Item 37

A woman who is heterozygous for brown eyes (blue is recessive) and heterozygous for brown hair (blond is recessive) marries a man who has blond hair and is heterozygous for brown eyes. What is the probability they will have a son who has brown hair and brown eyes, and who is capable of fathering children with blue eyes?

A. 1/4

B. 1/2

C. 1/8

D. 1/16

E. This cannot be determined from the information given.

1. Item 38

The ion channel responsible for the plateau of the cardiac muscle cell action potential is the:

A. Na+ leak.

B. K+ leak.

C. voltage-gated Na+.

D. voltage-gated K+.

E. voltage-gated Ca2+.

1. Item 39

The functions of the large intestine include all of the following EXCEPT:

A. fecal storage.

B. reabsorption of water.

C. production of vitamin K by intestinal bacteria.

D. digestion and absorption of nutrients not fully digested in the small intestine.

E. reabsorption of electrolytes.

1. Item 40

During which phase of the ovarian cycle are increasing levels of estrogen secreted?

A. Secretory phase

B. Follicular phase

C. Ovulatory phase

D. Menstrual phase

E. Proliferative phase

1. Item 41

Telomerases are important in the replication of eukaryotic DNA because they:

A. connect leading and lagging strand fragments to create a contiguous linear chromosome.

B. remove methyl groups from protected sequences to allow replication.

C. generate the repetitious DNA sequences at the end of linear chromosomes.

D. provide primers for leading strand synthesis.

E. unwind the double helix for replication to begin.

1. Item 42

In the absence of ATP, which step(s) of the sliding filament theory CANNOT occur?

I. Myosin head groups attach to actin. II. Myosin “power stroke” pulls actin toward center of sarcomere. III. Myosin releases actin. IV. Myosin head groups are cocked back to “reset” to original position.

A. II only

B. II and III only

C. III and IV only

D. I and II only

E. II, III, and IV only

1. Item 43

Which of the following structures are NOT made of microtubules?

A. Microvilli

B. Mitotic spindle

C. Flagella

D. Cilia E. Centrioles

1. Item 44

Which blood vessel carries oxygenated blood to the left atrium of the heart?

A. Aorta

B. Pulmonary artery

C. Pulmonary vein

D. Superior vena cava

E. Coronary artery

1. Item 45

Blood filtration by the kidney takes place at the:

A. vasa recta.

B. proximal tubule.

C. renal artery.

D. glomerular capillaries.

E. distal tubule.

1. Item 46

A competitive inhibitor causes:

A. Vmax to decrease and Km to remain unchanged.

B. Vmax to remain unchanged and Km to decrease.

C. Vmax to remain unchanged and Km to increase.

D. Vmax to increase and Km to remain unchanged.

E. neither Vmax nor Km to be affected.

1. Item 47

Which of the following is a characteristic of prokaryotic protein synthesis?

A. Prokaryotic mRNA is monocistronic.

B. The first amino acid translated is formyl-methionine.

C. Prokaryotic transcription requires three separate RNA polymerases.

D. The mRNA must be polyadenylated at the 3’ end.

E. Introns must be spliced out before translation can occur.

1. Item 48

What attributes of prions makes them difficult to destroy?

A. Tough outer cell wall

B. Resistance to heat and chemical treatment

C. Ability to mutate quickly

D. Resemblance to human cell surface receptors

E. Integration into the host cell genome

1. Item 49

The role of surfactant in the respiratory system is to:

A. stimulate the diaphragm.

B. increase the lipid solubility of oxygen, allowing it to diffuse more easily into the blood.

C. dilate the bronchial tubes.

D. reduce surface tension in the alveoli.

E. trap inhaled dirt and dust particles.

1. Item 50

Which of the following contributes the most to maintenance of the normal resting membrane potential of cells?

A. K+ leak channels

B. Na+ leak channels

C. Na+/K+ ATPase

D. Opening of voltage-gated Na+ and K+ channels

E. Establishment of a strong Na+ concentration gradient

1. Item 51

Including the ATP used for amino acid activation/tRNA loading, approximately how many ATP equivalents are required to synthesize a 200 amino acid protein?

A. 200

B. 400

C. 600

D. 800

E. 1000

1. Item 52

Which best described the process by which rod cells are activated?

A. light strikes a depolarized rod cell → Na+ channels close → hyperpolarization of rod stops release of an inhibitory neurotransmitter

B. light strikes a depolarized rod cell → Na+ channels open → hyperpolarization of rod stops release of an inhibitory neurotransmitter

C. light strikes a rod cell at resting membrane potential → Na+channels open → depolarization of rod leads to an action potential

D. light strikes a rod cell at resting membrane potential → K+channels open → hyperpolarization of rod stops release of an inhibitory neurotransmitter

E. light strikes a depolarized rod cell → K+ channels open → hyperpolarization of rod stops release of an inhibitory neurotransmitter

1. Item 53

Which of the following bacterial auxotrophs should be grown in a lactose-based medium containing arginine and threonine but lacking histidine?

A. Arg– Lac+ Thr– His+

B. Arg– Lac– Thr+ His–

C. Arg+ Lac– Thr+ His–

D. Arg+ Lac+ Thr+ His–

E. Arg– Lac– Thr– His+

1. Item 54

The area of the cerebral cortex which controls voluntary motor function and complex reasoning is the:

A. parietal lobe.

B. frontal lobe.

C. temporal lobe.

D. occipital lobe.

E. olfactory lobe.

1. Item 55

In an operon, which of the following best describes the promoter?

A. It is the binding site for the repressor.

B. It is a molecule that inactivates the repressor and permits transcription.

C. It activates the repressor-inducer complex to permit transcription.

D. It is the binding site for met-tRNAmet to initiate translation.

E. It is the binding site for RNA polymerase.

1. Item 56

In muscle cells undergoing anaerobic respiration (i.e., fermentation):

A. pyruvate is reduced to ethanol.

B. pyruvate is oxidized to ethanol.

C. pyruvate is reduced to lactic acid.

D. pyruvate is oxidized to lactic acid.

E. none of the above. Muscle cells cannot undergo fermentation.

1. Item 57

Spermatogenesis occurs in the:

A. vas deferens.

B. epididymis.

C. scrotum.

D. seminiferous tubules.

E. none of the above.

1. Item 58

Cholecystokinin functions in digestion to cause the release of:

I. trypsinogen. II. bile. III. pepsinogen.

A. II only

B. I and II only

C. I and III only

D. II and III only

E. I, II, and III

1. Item 59

Alcohol inhibits the production of antidiuretic hormone. A person who has consumed alcohol would have:

A. increased urine output and increased urine osmolarity.

B. decreased urine output and increased urine osmolarity.

C. increased urine output and increased blood osmolarity.

D. decreased urine output and decreased blood osmolarity.

E. increased urine output and decreased blood osmolarity.

1. Item 60

Which of the following muscle fiber types uses oxidative metabolism?

I. Type I II. Type IIa III. Type IIb

A. I only

B. I and II only

C. III only

D. II and III only

E. I, II, and III

1. Item 61

Cell surface proteins, such as receptors, begin synthesis on cytoplasmic ribosomes, but are targeted by signal sequences (particular amino acid sequences within the protein) to the rough ER to complete their synthesis. Which of the following statements concerning signal sequences is/are true?

I. They are hydrophobic. II. They can be found at the beginning of the protein’s amino acid sequence. III. They are always cleaved from the mature protein upon completion of translation. IV. They can be found in the middle of the protein’s amino acid sequence.

A. I and II only

B. II and III only

C. I, II, and III only

D. III only

E. I, II, and IV only

1. Item 62

Carbon dioxide is a small hydrophobic molecule that can freely diffuse across plasma membranes. In the bloodstream, it combines with water to form carbonic acid. Excess carbon dioxide provides the primary drive for respiration, primarily as dissociated carbonic acid. Low arterial PCO2 would cause all of the following physiological changes EXCEPT:

A. decreased HCO3– reabsorption by the kidney.

B. increased HCO3– transport out of the cerebrospinal fluid.

C. faster ventilation rate.

D. decreased PCO2 in the cerebrospinal fluid.

E. increased plasma pH.

1. Item 63

Aerobic respiration in eukaryotes produces less ATP per glucose molecule than aerobic respiration in prokaryotes. This is because:

A. prokaryotes can produce a larger proton gradient across the inner mitochondrial membrane, thus causing a greater driving force for ATP synthesis.

B. eukaryotes must actively transport glucose into the mitochondria where respiration occurs.

C. prokaryotes can generate 2.5 ATP per FADH2 molecule, whereas eukaryotes can only generate 1.5 per FADH2.

D. the electrons from cytoplasmic NADH in eukaryotes are shuttled to ubiquinone instead of NADH dehydrogenase.

E. fermentation and the tricarboxylic acid cycle can run simultaneously in prokaryotes, generating two additional ATP per glucose molecule.

1. Item 64

The autonomic nervous system uses several different neurotransmitters in several different locations with several different receptor types. Which of the following receptors binds ACh at parasympathetic target organs?

A. Muscarinic receptors

B. Nicotinic receptors

C. α receptors

D. β receptors

E. Adrenergic receptors

1. Item 65

All of the following statements about stem cells are true EXCEPT:

I. adult stem cells can be collected from the bone marrow and are multipotent. II. the zygote and early cells of the embryo are totipotent. III. embryonic stem cells are pluripotent and can become any of the embryonic germ layers or the trophoblast.

A. I only

B. II only

C. I and III only

D. II and III only

E. I, II, and III

1. Item 66

HIV, the virus that causes AIDS, is a (+)RNA retrovirus. A significant concern in the treatment of HIV infection with drugs is the development of drug-resistant virus. Which of the following is most likely to contribute to the development of drug-resistant HIV?

A. Mutation of the virus after insertion into the host-cell genome

B. Frequent random errors in transcription of the viral genome by host-cell enzymes

C. Viral proteins folding differently in the presence of drug than in its absence

D. Covalent modification of viral nucleic acids by the drug

E. Mutation of viral reverse transcriptase after infection of the host cell

1. Item 67

A portion of prokaryotic mRNA has the following base sequence: 5’ACAUCUAUGCCACGA3’. Which of the following could result from a mutation that changes the underlined base to A?

I. Inhibition of initiation of translation II. Truncation of the polypeptide III. A shift in the reading frame for translation

A. I only

B. II only

C. II and III only

D. I and II only

E. I, II, and III

1. Item 68

During systole, the left ventricle of the heart pumps about 60% of its blood out to the body. This amount is referred to as the ejection fraction. The blood that remains in the ventricles at the end of ejection is called the residual volume, and is typically about 50 mL. Congestive heart failure is caused by a reduced pumping efficiency of the left ventricle. This could result in all of the following EXCEPT:

A. congestion of blood in the pulmonary artery.

B. residual volume less than 50 mL.

C. decreased aortic pressures and blood flow.

D. right ventricular failure.

E. pulmonary edema.

1. Item 69

Polydactyly is a disorder caused by a dominant allele that results in extra fingers. If the allele causing polydactyly is present at a frequency of 0.2 in a certain large, isolated, randomlymating population, what is the frequency of affected individuals in this population?

A. 0.04

B. 0.32

C. 0.36

D. 0.64

E. 0.96

1. Item 70

Epidural block is a form of anesthesia commonly used to prevent the pain of childbirth. It involves the injection of a somewhat lipid-soluble anesthetic into the epidural space (a fat filled region outside the dura mater of the spinal cord). This successfully blocks the pain of uterine contractions during labor without blocking the contractions themselves. This is because:

A. the somatic motor neurons innervating the uterus are not affected by the anesthetic.

B. injection of the anesthetic occurs too low on the spinal column to affect the uterus.

C. the anesthetic does not cross the dura mater and thus does not affect the spinal cord.

D. the blood vessels that pick up and transport the anesthetic do not travel to the uterus.

E. the contractions are stimulated by hormonal stimuli that are not affected by the anesthetic

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Biology Hw

December 15, 2023/in Uncategorized /by Daniel Jennings

Note: Complete the questions asked in Part A and Part B.

Part A: Briefly answer the following questions. Make sure you cite references in APA. Your answer must be 100% original.

Question 1

(Hint: Look in “Patterns- The family tree”)

What is the trait that distinguishes primates, rodents/ rabbits, crocodiles, and dinosaurs/ birds from amphibians and earlier lineages?

Question 2

Would you expect a bird wing and a butterfly wing to be homologous or analogous structures? Explain.

Question 3

In your own words, list and define the four mechanisms of evolution.

Question 4

(Hint: Look in “Mechanisms- Natural selection”)

In your own words, give an example in nature of how natural selection works.

Question 5

In your own words, describe the difference between microevolution and macroevolution.

Part B: Multiple choice questions

Question 1

In the following phylogenetic tree, which of the following are in the clade that has a therian mammal ancestor?

		monotremes and eutherians
		lepidosaurs and archosaurs
		monotremes and marsupials
		marsupials and eutherians

Question 2

In the following phylogenetic tree, the unique lineage of archosaurs is represented by:

		a red line
		a green line
		a blue line
		a black line

Question 3

In the following phylogenetic tree, which of the following is not a shared derived characteristic of therian mammals?

		pouch
		holoblastic cleavage
		placentation
		viviparity

Question 4

(Hint: look in “Mechanisms- Descent with modification”)

In a population of beetles which can be either green or brown in color, the gene (allele) frequency of green beetles in 2009 was measured to be 36% and increased to 52% in 2010. The gene (allele) frequency of brown beetles in 2009 was measured to be 64% and decreased to 48% in 2010.

True of False? This population of beetles is evolving.

		True
		False

Question 5

Which of the following is the best example of the principle of “fitness”?

		a white rabbit living on a forested hill side compared to a brown rabbit living there
		gorilla males with large testicles consistently producing more offspring than gorilla males with small testicles
		the most dominant chimpanzee male in the group eating more often than less dominant males
		a giraffe having thicker,spottier fur than another giraffe

Question 6

Which of the following statements is TRUE?

		mutation are non-random
		only germline mutations can affect evolution
		natural selection is random
		mutation always affect the phenotype to the same extent

Question 7

Hummingbirds feed on flower nectar and often have a beak whose shape is adapted specifically to only one flower shape, fitting in no other flower species. As a result, this hummingbird may only feed on that particular flower and is its only pollinator, creating a mutual dependency between the two species.

This is an example of ___________.

(spelling counts; lower case letters only, please).

Question 8

A field biologist discovers a population of pocket mice in Nebraska which has a very different phenotype of the other populations of pocket mice in the area.

Which of the following is the best strategy the biologist should use in order to establish whether or not she has found a new species?

		compare the color, size, shape, and any other physical traits between the various populations to the newly discovered one and if they look at least 95% the same, consider them the same species.
		check to see what kind of habitat they live in, and if it is the same, consider them the same species
		check to see what they eat, at what time of the year they breed, how many offspring they generally produce, and what their social structure is, and if it is the same, consider them the same species
		check to see if they would produce viable and fertile offspring when brought together to mate. If yes, then consider them the same species

Question 9

The fact that a mule (hybrid offspring of a horse and a donkey) is sterile is an example of:

		reduction of gene flow
		genetic drift
		reproductive isolation
		geographic isolation

Question 10

True or False. The mechanisms causing microevolution are different from those of macroevolution.

		True
		False

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Wildlife

December 15, 2023/in Uncategorized /by Daniel Jennings

*Read chapters 11 (p. 183-193) and 12 (p. 197-215) in Spotila, then answer the questions below.

1) While the leatherback has a soft carapace, the flatback has the densest and hardest

carapace of all sea turtles. a. True b. False

2) Since sea turtles are cold-blooded, they can’t exist in the frigid North Atlantic Ocean.

a. True b. False

This leatherback is crying because: a. the process of laying eggs is very painful b. none of these answers is correct c. the sand from the beach is irritating the eye d. it is ridding its body of excess salt e. it is shedding excess heat through evaporative transfer f. the process of crawling on land is very difficult

4) The flatback is immune to the factors affecting the populations of other sea turtle

species because it is limited in distribution to the continental shelf of Australia, and Australia has very strong turtle protection laws.

a. True b. False

5) What is the scientific name of the leatherback turtle?

6) Rain is no problem for most sea turtle hatchlings. In fact, the cool beach and overcast sky provides protection from the sun and predators.

a. True b. False

7) Proportional to its body size, the flatback turtle produces the largest egg of any sea

turtle. These large eggs may be an adaptation for surviving on very hot nesting beaches. a. True b. False

8) Today, there are about 35,000 adult female leatherbacks in the world, with most of

them in the eastern Pacific. a. True b. False

9) What is the scientific name for the flatback turtle?

10) Flatback embryos will die if the nest temperature exceeds 90 degrees F (32 degrees C).

a. True b. False

11) The major flatback nesting colonies are located between Australia and New Zealand.

a. True b. False

12) Unlike all other species of sea turtles, flatbacks lack an oceanic phase.

a. True b. False

13) When leatherback nests are undisturbed by predators and people, hatching success can

be as high as 90%. a. True b. False

14) Although leatherbacks can eat jellyfish, it simply isn’t possible for these large turtles to

support their caloric needs with a prey (jellyfish) that is made up primarily of water. a. True b. False

15) Unlike other sea turtles, the scutes on the carapace of the leatherback seem to repel ocean plants and animals from attaching to it.

a. True b. False

16) Spotila estimates that an individual leatherback in the Pacific is likely to be caught on a longline fishing hook:

a. once per year b. once every 3-5 years. c. once every 6-10 years d. once every 2 years e. leatherbacks are so rare in the Pacific, that they aren’t caught at all.

17) “CITES” stands for:

18) The _________________ is the largest turtle in the world.

19) Sea turtle tags have evolved over the years, from plastic and metal flipper tags to PIT (“passive integrated transponder”) tags. All tags have a similar failure rate, however, so standardization is not an issue.

a. True b. False

20) _____________________ are capable of diving to great depths on one breath. They are

also capable of swimming and feeding in cold waters due to their ability to keep their internal temperature higher than the ambient temperature.

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ANY ONE CAN HELPS ME WITH THIS REPORT ?

December 15, 2023/in Uncategorized /by Daniel Jennings

Experiment

14A

Experiment 14A

Neuromuscular Reflexes

Neuromuscular Reflexes

The automatic response of a muscle to a stimulus is called a reflex. The patellar reflex results from tapping the patellar tendon below the knee with a reflex hammer. This causes contraction of the quadriceps muscle and extension of the leg. Stretching of the muscle activates nerve impulses which travel to the spinal cord. Here the incoming impulses activate motor neurons, which travel back to the muscle and result in muscle contraction. This reflex arc is primarily a spinal reflex, but is influenced by other pathways to and from the brain (Figure 1).

A reflex may be reinforced (a term used by neurologists) by slight voluntary contraction of muscles other than the one being tested. For example, voluntary activation of arm muscles by motor neurons in the central nervous system “spills over” to cause a slight activation of the leg muscles as well. This results in the enhancement of the patellar reflex. There are other examples of central nervous system influences on reflexes. Health care professionals use knowledge of these influences to aid in diagnosis of conditions such as acute stroke and herniated lumbar disk, where reflexes may be absent; and spinal cord injury and multiple sclerosis, which may result in exuberant reflexes.

In this experiment, you will use an EKG Sensor to compare the speed of a voluntary vs. a reflex muscle action and to measure the relative strength (amplitude) of the impulse generated by a stimulus with and without reinforcement. You will make a rough calculation of nerve impulse speed using data generated by an Accelerometer used in conjunction with the EKG sensor.

Important: Do not attempt this experiment if you have pain in or around the knee. Inform your instructor of any possible health problems that might be exacerbated if you participate in this exercise.

Objectives

In this experiment, you will

 Graph the electrical activity of a muscle activated by a reflex arc through nerves to and from the spinal cord.

 Compare the relative speeds of voluntary and reflex muscle activation.

 Associate muscle activity with involuntary activation.

 Observe the effect of central nervous system influence on reflex amplitude.

 Calculate the approximate speed of a nerve impulse.

 Compare reflex response and electrical amplitude in different subjects.

MATERIALS

LabQuest	reflex hammer
LabQuest App	cable tie, 10 cm long
Vernier EKG Sensor	cloth tape measure
Vernier 25-g Accelerometer	pen
electrode tabs

PROCEDURE

Each person in the group will take turns being subject and tester.

Part I Voluntary Activation of the Quadriceps Muscle

1. Connect the EKG Sensor and Accelerometer to LabQuest. Choose New from the File menu. If you have older sensors that do not auto-ID, manually set up the sensors.

2. On the Meter screen, tap Rate. Change the data-collection rate to 100 samples/second and the data-collection length to 30 seconds. Select OK.

3. Connect the Accelerometer to the reflex hammer using the cable tie, as shown in Figure 2. Place the Accelerometer cable toward the back of the hammer so it does not get in the way.

4. Have the subject sit comfortably in a chair that is high enough to allow his/her legs to dangle freely above the floor.

5. Attach two electrode tabs above one knee along the line of the quadriceps muscle between the knee and the hip. The tabs should be 5 cm and 13 cm from the middle of the patella (see Figure 3). Place a third electrode tab on the lower leg.

6. Attach the red and green leads to the electrode tabs above the knee with the red electrode closest to the knee. Attach the black lead (ground) to the electrode tab on the lower leg.

7. Start data collection. If the graph has a stable baseline as shown in Figure 4, stop data collection continue to Step 8. If your graph has an unstable baseline, stop data collection and collect a new set of data by starting data collection again. Repeat data collection until you have obtained a stable baseline for 5 s.

8. Collect voluntary activation data. Note: Read the entire step before collecting data to become familiar with the procedure.

a. Have the subject close his/her eyes, or avert them from the screen.

b. Start data collection.

c. After recording 5 s of stable baseline, swing the reflex hammer briskly to contact the table or other surface that generates a sound.

d. The subject should kick his/her leg out immediately upon hearing the sound.

e. Continue obtaining reflexes (repeat parts c and d of this step) so that you record 5–10 kicks during the data-collection period.

9. Determine the time elapsed between striking the table surface with the reflex hammer and the contraction of the quadriceps muscle.

a. To analyze the data, tap and drag across the EKG data to highlight the area from just before the table was struck to just after the muscle contraction.

b. Choose Zoom In from the Graph menu.

c. To examine the data pairs on the acceleration graph, tap any data point. As you tap each data point, the acceleration and time values are displayed to the right of the graph.

d. Tap the first high peak (which corresponds to the first kick) on the acceleration graph (Figure 5). This peak indicates the time at which the table surface was struck. Record this time in Table 1.

e. Tap the first high peak (Kick 1) on the EMG graph. This peak indicates the time at which the quadriceps muscle contracted. Record this time in Table 1.

f. Choose Autoscale Once from the Graph menu.

g. Repeat this process of zooming in and determining the time of the hammer strike and reflex for a total of five stimulus-kick pairs.

h. Calculate the change in time between the hammer strike and reflex for the five stimulus-kick pairs and then calculate the average change in time for all five pairs. Record the values in Table 1.

Part II Patellar Reflex

10. Locate the subject’s patellar tendon by feeling for the narrow band of tissue that connects the lower aspect of the patella to the tibia. Place a pen mark in the center of the tendon, which can be identified by its softness compared with the bones above and below (see Figure 6).

11. Start data collection. If your graph has a stable baseline as shown in Figure 4, stop data collection and continue to Step 12. If your graph has an unstable baseline, stop and collection and repeat data collection until you have obtained a stable baseline for 5 s.

12. Collect patellar reflex data. Note: Read the entire step before collecting data to familiarize yourself with the procedure.

a. Have the subject close his/her eyes, or avert them from the screen.

b. Start data collection.

c. After recording 5 s of stable baseline, swing the reflex hammer briskly to contact the mark on the subject’s tendon. If this does not result in a visible reflex, aim toward other areas of the tendon until the reflex is obtained.

d. Continue obtaining reflexes so that you record 5–10 reflexes during the collection period.

13. Determine the time elapsed between striking the patellar tendon with the reflex hammer and the contraction of the quadriceps muscle.

a. To analyze the data, tap and drag across the EKG data to highlight the area from just before the tendon was struck to just after the muscle contraction.

b. Choose Zoom In from the Graph menu.

c. Tap the first high peak (which corresponds to the first kick) in the Accelerometer graph (Figure 5). This peak indicates the time at which the tendon was struck. Record this time in Table 2.

d. Tap the first high peak (Kick 1) in the EMG graph. This peak indicates the time at which the quadriceps muscle contracted. Record this time in Table 2.

e. Choose Autoscale Once from the Graph menu.

f. Repeat this process of zooming in and determining the time of the hammer strike and reflex for a total of five stimulus-kick pairs.

g. Calculate the change in time between the hammer strike and reflex for the five stimulus-kick pairs and then calculate the average change in time for all five pairs. Record the values in Table 2.

Part III Reflex Reinforcement

14. With the subject sitting comfortably in a chair, start data collection. If your graph has a stable baseline, stop data collection and continue to Step 15. If your graph has an unstable baseline, stop data collection and repeat until you have obtained a stable baseline for 5 s.

15. Collect patellar reflex data without and with reinforcement. Note: Read the entire step before collecting data to familiarize yourself with the procedure.

a. Have the subject close his/her eyes, or avert them from the screen.

b. Start data collection

c. After recording a stable baseline for 5 s, swing the reflex hammer briskly to contact the mark on the subject’s tendon. If this does not result in a visible reflex, aim toward other areas of the tendon until the reflex is obtained.

d. After 5 or 6 successful reflexes have been obtained, have the subject reinforce the reflex by hooking together his/her flexed fingers and pulling apart at chest level, with elbows extending outward (see Figure 7).

e. Continue obtaining reflexes until data collection is completed at 30 s. A total of 10–15 reflexes should appear on the graph.

16. Determine the minimum, maximum, and ∆y for the depolarization events in this run.

a. Tap and drag across the EMG graph to select the first area of increased amplitude (depolarization) in this run (see Figure 8).

b. Choose Zoom In from the Graph menu and ensure that you have selected an area of data that represents the first area of increased amplitude (depolarization).

c. Choose Statistics ► Potential from the Analyze menu.

d. Record the minimum and maximum for this depolarization in Table 3, rounding to the nearest 0.01 mV.

e. Determine and record the ∆y value (amplitude).

f. Choose Statistics from the Analyze menu to turn off statistics.

g. Choose Autoscale Once from the Graph menu.

17. Repeat this process for each of five unreinforced and five reinforced depolarization events, using the Accelerometer to identify each primary reflex. Ignore rebound responses. Record the appropriate values in Table 3.

18. Determine the average amplitude of the reinforced and unreinforced depolarization events examined. Record these values in Table 3.

DATA

Table 1

Kick 1

Kick 2

Kick 3

Kick 4

Kick 5

Average

Time of muscle contraction (s)

Time of stimulus (s)

∆ t (s)

Table 2

Reflex 1

Reflex 2

Reflex 3

Reflex 4

Reflex 5

Average

Time of muscle contraction (s)

Time of stimulus (s)

∆ t (s)

Table 3
	Reflex without reinforcement	Reflex with reinforcement
Reflex response	Max (mV)	Min (mV)	∆mV	Max (mV)	Min (mV)	∆mV
1
2
3
4
5
Average values

Data Analysis

1. Compare the reaction times for voluntary vs. involuntary activation of the quadriceps muscle. What might account for the observed differences in reaction times?

2. Using data from Table 2, calculate speed at which a stimulus traveled from the patellar tendon to the spinal cord and back to the quadriceps muscle (a complete reflex arc). To do this, you must estimate the distance traveled. Using a cloth tape measure, measure the distance in cm from the mark on the patellar tendon to the spinal cord at waist level (straight across from the anterior-superior iliac spine–see Figure 9). Multiply the distance by two to obtain the total distance traveled in the reflex arc. Once this value has been obtained, divide by the average ∆t from Table 2 and divide by 100 to obtain the speed, in m/s, at which the stimulus traveled.

3. Nerve impulses have been found to travel as fast as 100 m/s. What could account for the difference between your answer to Question 2 and this value obtained by researchers?

4. Assume the speed of a nerve impulse is 100 m/s. How does this compare to the speed of electricity in a copper wire (approx. 3.00 ( 108 m/s)?

5. Compare the data you obtained in this experiment with other members of your group/class. Can individual differences be attributed to any physical differences (body shape/size, muscle mass, physical fitness level)?

extension

1. Explore the ankle and elbow reflexes.

2. Perform the experiment with the subject watching the reflex hammer as it hits the patellar tendon. Compare this data to data gathered while the subject is focusing on an object elsewhere in the room.

Figure 1

Figure 2

Figure 3

Figure 4

Figure 5

Figure 6

Figure 7

Figure 8

Figure 9

Human Physiology with Vernier 14A –

14A – Human Physiology with Vernier

Human Physiology with Vernier 14A –

Week4 Project

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Biology Hw

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Wildlife

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