Trolley Dodgers Case

Executive Summary The Trolley Dodgers was exposed that it had internal control problems existed. The other hand, found that employees embezzlement. The first part of this report identify and explain the characteristics of employee fraud indicated in Dodgers case. such as perpetrator must gains the trust or confidence of the person or company being defrauded. etc And then, the second part is explain the internal control weaknesses and understanding internal control objectives . The third part based on the understanding of the Committee of Sponsoring Organisations ‘internal control. Final part is recommendation for Dodgers internal control problems. Table of Contents Introduction3 Characteristics of the employee fraud in Trolley Dodgers case3 The internal control weaknesses in the Dodgers` payroll system4 The critical evaluation of the internal control problems in the Dodgers` payroll system5 Recommendation for Dodgers internal control problems7 Reference List:9 Introduction In this report, I will be divided into four parts. The first part will cover Identify and explain the characteristics of employee fraud . The second part is explain the internal control weaknesses that were evident in the Dodger’ payroll system . the internal control weaknesses include: no independent check and Dodgers don't have separation of duties, etc. The third part is to understanding the Committee of Sponsoring Organisations ‘ internal control framework to evaluate internal control problems. The COSO's internal control framework have five interrelated components. the five components includes: Control environment ,Control activities, Risk assessment , Information and communication and Monitoring. The final part is recommendation for Dodgers internal control problems. Characteristics of the employee fraud in Trolley Dodgers case Employee fraud is an employee within the company to improperly deceptive means to obtain the company's money or other property. Through understand to Romney and Steinbart for the employee fraud has a number of important characteristics. However, the analysis and interpretation in this case related to employee fraud Characteristics. One basic characteristics of employee fraud is perpetrator must gains the trust or confidence of the person or company being defrauded. In the case mentioned Edward Campos is operations payroll Chief. He is longtime working for the Dodgers . He was known not only for his work ethic but also for his loyalty to the club . However, His boss think Campos was on vacation ,He will came back to company and did the payroll. Dodgers Trusted him. The facts have proved that perpetrators has gained the trust of the company , His behavior is consistent with employee fraud of characteristics . Many employee fraud cases are the characteristics of perpetrators and employers to establish a good relationship of trust. Other case about Bess is cashier supervisor at the campus student health services(SHS)? she is trusted employee? she was able to commit this fraud undetected for nearly 13 years? why? But the answer is simply: Because don’t anyone suspected the SHS cashier supervisor because she was a trusted, well-liked employee. â€Å"Fraud research finds that most members of the general public fit the profile of the typical fraud perpetrator†(Peterson and Gibson 2003). But Dodgers’ case and Bess case similar, so to meet this characteristics of employee fraud. The fraud perpetrators use false or misleading information to obtain asset or money is the fundamental elements of employee fraud. This element is required no use other violent offenders, Other employee fraud is they the hide their tracks by falsifying records or other information (Romney and Steinbart 2009). Because he false wage income of workers, He registered about $ 2000 weekly wage employees. However, the real wages of workers earning $ 7 per hour. His salary more than 55% false. On the other hand, He completely controlled the payroll system for filling out the weekly payroll cards for the employees of the Dodgers. Because, He designed and implemented to payroll and only himself understand full payroll system. Other case admitted to manipulating work samples, falsifying records to cover up its poor performance as a Medicare contractor(Healthcare Financial Management 1998) . Demonstrate through their privileged position to falsifying records is general public fit the profile of the characteristics fraud perpetrator The internal control weaknesses in the Dodgers` payroll system Internal control refers the process implement by the corporate board of directors, managers and other staff, and provide reasonable assurance . The purpose of internal control is to ensure the reliability and accuracy of financial reporting, efficiency of operations, and compliance with laws and regulations. The internal control weakness in the Dodger’s payroll system include: 1. The Trolley Dodgers don't have independent check and performance . Because, Campos controlled the system so completely that he personally filled out the weekly payroll cards for each of the 400 employees of the Dodgers. 2. Trolley Dodgers should have must vacation for senior managers. Because, A management position working in a long time, then he will be more familiar with the internal control vulnerabilities, the possible implementation corruption. 3. The Dodgers don't have separation of duties, Campos is operations payroll chief. He designed and implemented of a new payroll system,. However, this is only himself understanding of all system operations. He was the trusted employee who got trusted too much, However,that Campos took advantage of his authorization. He came back during vacation to do the payroll. On the other hand, Camps routinely inflated the number of hours worked by several employees and then split the resulting overpayments fifty-fifty with those individuals. These employees pay $ 7 per hour, but these employees weekly wage approaching $2000. He did not ensure the integrity of assets and reliability of financial reporting. This information is also proved that the internal control failed to arrived goal of the segregation of duties. Enterprises to integrity and strengthen the internal organization, it is the economic activity of firms for planning, directing and controlling the organizational basis, the core problem is a reasonable segregation of duties. Under normal circumstances, Dealing with each business or the economy in the whole process a few important aspects, Companies need to be up to the two departments or two or more departments, two or more staff for the purpose of mutual control. The critical evaluation of the internal control problems in the Dodgers’ payroll system What is internal control ? Different people have different interpretations. General people to understand the internal control for the organization to reduce work of the decision-making errors and defects in the implementation of the control, These controls may be internal oversight, it may be management manuals, rules and regulations. These theories are not wrong, but not comprehensive. In accordance with the internal control theory, these are only part of the internal control, but not all. Internal control theory suggests that internal control is a systematic framework, It is built on the basis of risk management. The five elements include: Control environment ,Control activities, Risk assessment , Information and communication and Monitoring . (Romney and Steinbart 2009). We call this architecture as Committee of Sponsoring Organisations’ (COSO) internal control framework. The internal control integrated framework has been widely adopted as the principal way to evaluate internal controls. Will through the five elements to evaluate the internal control problems with the Dodgers’ payroll system. The control environment is the establishment, Strengthen or weaken the specific policies, procedures and their impact on the efficiency of the various factors, mainly refers to the major factor. Control environment have a direct impact on the implementation of internal control and execution of business objectives and related to the overall strategic objectives. Control environment, including the values of employees, personnel competence, management's business model, the allocation of rights and responsibilities. In this case have found problem is Trolley Dodgers no reasonable structure and clear division of responsibility approach. Because, Campos is payroll chief. However, Campos completely controlled the payroll system for filling out the weekly payroll cards for the employees of the Dodgers. Therefore, the formation of a single department, resulting in no mutual constraints of the internal control system. The control activates is Instruction is to help executive management policies and procedures. It throughout the organization, at all levels and functions, including a variety of activities such as approvals, authorizations, confirmed that adjustment, business performance evaluation, asset protection and separation of duties. The Trolley Dodgers don't have separation of duties, However,that Campos took advantage of his authorization. He came back during vacation to do the payroll. Risk assessment is to identify and analyze the process of achieving goals related risks, which with the economy, industry, regulatory and operating conditions are constantly changing, the need to establish a mechanism to identify and deal with the corresponding risks. Dodger’s case cannot be any problem in this regard. Information and communication is surrounding the control activities are information and communication. From internal and external information must be a certain format and time interval to confirm the capture and transfer to ensure the company's employees to perform their respective duties. Effective communication is a broad communication, including the enterprise from top to bottom, bottom-up and horizontal communication. Effective communication includes the relevant information with parties outside the enterprise effective communication and exchange, such as customers, suppliers, administration and shareholders. Dodgers does not have very good communication, so senior managers do not understand the financial statements of a problem. Monitoring is the entire business process must be monitored. Through the normal management and control activities and staff activities in the course of his duties to monitor, to evaluate the quality of operation of the system. Evaluation of different steps depending on the scope and implementation of risk assessment and monitoring program effectiveness. By understanding the Dodgers case can determine a great part of this monitoring problem. Dodgers not have normal company monitoring department. Lead to administrator can’t find employee fraud. Recommendation for Dodgers internal control problems Based on understanding of the COSO' internal control framework and the Dodgers facts, I recommend Dodgers to strengthen its internal control system. Internal controls perform three important point, segregation of duties , strengthen the monitoring and Must ensure that the accounting documents and accounting records of the completeness and correctness. All of those three are suitable for Dodgers’ situation. Three proposals are as follows: 1. When these functions are combined in one individual, it is possible to the misappropriation asset and conceal the crime by manipulating the related records ? such as overpayment 55% with those employee. So, When the economic activity of firms for planning, directing and controlling the organizational basis, the core problem is a reasonable segregation of duties. Under normal circumstances, dealing with the whole process of business of each economy, Must two department or more than two departments, two or more two employees take responsibility, its purpose is to restrict each other. Therefore, Separating the incompatible functions of cash recording and cash custody, independent check of cash received and cash deposited, The mandatory vacations with other personnel performing duties during the employee's absence. 2. Dodgers need to strengthen monitoring. However, it is necessary to establish an internal audit department. Internal audit is to strengthen the internal control system is a basic measure. Internal audit responsibilities include the review of accounts, It also includes inspection, evaluation of internal control system is perfect. Through the company's financial report of audit. The audit report submitted to the Board of Directors. Thus ensuring the company's internal control system more perfect. 3. Must ensure that the accounting documents and accounting records of the completeness and correctness. Because in this case found that the perpetrators falsified accounting documents. Conclusion Through the analysis of the Trolley Dodgers’ case, we found internal control have weakness It don't have separation of duties and don't have independent check and performance. Also, Dodgers had internal control issues according to the Committee of Sponsoring Organisations’ (COSO) internal control framework . Analysis of the case of internal control, and finally gives three suggestions. Recommendations include segregation of duties , strengthen the monitoring and Must ensure that the accounting documents and accounting records of the completeness and correctness. Reference List: Book references: Romney, MB & Steinbart, PJ 2009, Accounting information systems, 11th edn, Pearson Prentice Hall, Upper Saddle River. Academic Journal articles references: Bonita K Peterson and Thomas H Gibson. ‘Student health services: a case of employee fraud’ In Journal of Accounting Education 2003 21(1):61-73 HFM (Healthcare Financial Management); ‘ Illinois Medicare carrier guilty of fraud, agrees to a $144 million settlement. ’ September 98, Vol. 52 Issue 9, p10, 1/4p LIN LIN Trolley Dodgers Case CASE STUDY: THE TROLLEY DODGERS 1. Identify the key audit objectives for a client’s payroll function. Comment on both objectives related to tests of control and those related to tests of control s and those related to substantive audit procedure. The key audit objectives for client’s payroll function in this Trolley Dodgers Case are: i. Occurrence ii. Completeness iii. Accuracy iv. Posting & Summarization v. Classification vi. Timing i. Key Audit Objective : Occurrence Dodgers must recorded payroll payments for existing employees only and should have separation of duties for each task. Test of Control: Examine internal control to see if the payroll payments are for exiting work and existing employees. The test could be examining all the workers time cards, personnel files and review organization chart. They also can discuss with employees and observe duties being performed. The tests would examine printouts of transactions rejected by the computer as having nonexistent employee numbers. Substantive Test of Transactions: The test to see if the right dollar amount in the payrolls were recorded and paid properly. They also test to review large dollar amount in the journal entries, general ledger and payroll earnings. Examine cancelled checks for proper endorsement could be compare with a personnel record. ii. Key Audit Objective : Completeness Dodgers must record all existent payroll transactions. Test of Control: The test is to see if the existing payrolls are recorded. If employees do not get any payment, so they can directly report to the employer. They also test to review the renumbered payroll check to find the missing one. Substantive Test of Transaction: They can compare the book and payroll bank statement. Therefore, they will prove the bank reconciliation and can look for unmatched dollars amount. iii. Key Audit Objective : Accuracy Dodgers recorded payroll transactions are for the amount of time actually worked and at the proper pay rates accuracy. Test of Control: The test is to see if the right hours and right rate are recorded and tax withholding is correct. Batch totals are compared with computer summary reports. Auditors could examine authorization in payroll records and personnel files. Substantive Tests of Transaction: To test for exact dollar amount, auditors could recalculate gross and net pay. They also can compare pay rate with the industry, review cancel check withholdings by referring to tax tables and authorization forms in personnel file. iv. Key Audit Objective: Posting and Summarization. Dodgers recorded payroll transaction properly included in the master file also properly summarized. Test of Control: When payroll master file totals are compared with general ledger totals, auditors should examine initialed summary total reports indicating that comparison has been made. They also must examine indication of internal verification. Substantive Test of Transaction: Test clerical accuracy by footing the payroll journal and tracing postings to the journal ledger and the payroll master files. v. Key Audit Objective : Classification Dodgers classify all payroll transaction properly and efficiently. Test of Control: They should review charts of accounts. If the account classifications are internally verified, then they can examine indication of internal verification. Substantive Test of Transaction: They can review time cards and job ticket, and trace through to labor distribution. They should compare classification with chart of accounts or procedures manual. vi. Key Audit Objective : Timing Dodger must record all payroll transaction immediately, on the correct date and right amount. Test of Control: Auditors should examine procedures manual and observe when recording takes place and examine indication of internal verification. Substantive Test of Transaction: The auditor compare date on checks with date in the payroll journal and compare date on check with date the check cleared the bank. 2. What internal control weaknesses were evident in the Dodgers’ payroll system? Internal control is a process, affected by an entity’s board of director, management and other personnel, designed to provide reasonable assurance regarding the achievement of objectives in reliability of financial reporting, effectiveness and efficiency of operations and compliance with laws and regulations. Internal control weakness in the Dodgers’ Payroll System are from the design of internal control, no independent check and performance, no separation of duties, the weakness of work environment, and required vacation for senior manager. . Design of internal control Campos, the operations payroll chief have designed the internal control by himself and implemented a new payroll system that only can be fully understand by him. As we know, the purpose of design the internal control is to prevent or detect material misstatement in the financial statement. Due to this case, Campos can easily commit fraud because there are no other people that can understand the design of the internal control. ii. No independent check and performance Campos controlled the system so completely that he personally filled out the weekly payroll card for each of the four hundred employees. He can record any fraudulent statement because there is no evidence that shows whether the record is reliable or not. iii. No separation of duties Campos took advantage of his authorization because he was the trusted employee who got trusted too much from Dodges’. When he was on vacation, he came back and did the payroll. There is no separation of the custody of assets from accounting. A person who has temporary or permanent custody of an asset should not account for that asset. This is because by allowing one person to perform both function increases the risk of that person disposing of the asset for personal gain and adjusting the records to cover up the theft. As we can see in this case, Campos was the only one who responsible for every task. iv. Weakness of the work environment There is collusion between employees and management. This showed that both Campos and his cohort have low work ethic. Campos routinely inflated the number of hours worked by several employees and then split the resulting over payment fifty-fifty with those individuals. In addition to this, Campos also embezzle several hundred thousand dollars from his employer. 3. Identify audit procedure that might have led to the discovery of the fraudulent scheme mastermind by Campos. Audit procedure is the detailed instruction for the collection of a type of audit evidence that is to be obtained at some time during the audit. i. The auditor must understand clearly the flow chart Auditor should go through the Dodger’s payroll flow chart. The auditor must understand clearly the flow chart. From that, the auditor can trace how the payroll system is going on actually. Then, the auditor would see there are no independent checks that have been done by Campos. The payroll department also does not have segregation of duties and all that work is done by Campos only. ii. The auditor can interview employees in payroll department. The auditor can interview employees in payroll department. The auditor can ask whatever question that they think it’s very important and need to know. Like, how much Campos pay for daily operations works for every level of staff, and how Campos manage the time card. The auditor will know more detailed about the payroll process. ii. The auditor test for nonexistent employees For make sure the all transaction that have recorded by Campos and payroll department is really exist and they make payment to the non fictitious employees, the auditor compare names on cancelled checks with the time card have created. The auditor can scan the endorsement on cancelled checks. Furthermore, auditor also can make comparison on personal fi les of employees with time card that created. Other than that, the auditor can run test of control by selected transaction in the payroll with Human Resources department. The auditor can select a week check transaction and examine the first fifty checks, select the fifty checks with the largest amounts, select the checks randomly or select those checks the auditor thinks are most likely to be in error or a combination of this method could be used. Besides that, the auditor request surprise payroll payoff from payroll department. When the auditor requests for payroll payoff suddenly, for sure the payroll department do not chance and do not have enough time to make correction on their system. So, Auditor will see the real transaction that have make by that department. Finally, the uditor can trace the misstatement, fraud and error easily. iv. The auditor tests for fraudulent hours Other than that, the auditor also can reconcile the total hours paid in the payroll records with and independent record of hours worked. Auditor would see, if payroll record transaction is true based on the time card or not. The auditor can trace if the record keeping employee s have intention to do that fraud. v. The auditor compare pay rates with the same positions in other baseball team in the league. The auditor also should understand business nature and make comparison with another similar business nature. From that result, the auditor will know how much is exactly pay rates usually paid to the professional baseball. After done that activity, the auditor is able to identify the pay rates that put by Campos to the every level worker is it relevance or not. vi. The auditor examines the large payroll checks. Last steps, that auditor use to discover the fraud is by examine the largest payroll checks out. The auditor reconciles the checks between the payroll record, time card, and all relevance data. Auditor would see which one fictitious transaction that has been made by Campos.

Prescribing event?

Abstract This report provides information on a prescribing event, which is conducted for a 70-year-old woman, who is bed bound as a result of superficial wound on left sheen. The prescribing event is adequately structured to present important details related to patient’s condition, as her holistic needs have been thoroughly considered by the student district nurse, who has been accompanied by her practice teacher during the event. The prescribing decision taken by the nurse related to prescribing a primary dressing and Allevyn Gentle Border as a secondary dressing. It has been identified that this decision is evidence-based considering its extensive benefits, as outlined in research. Introduction The purpose of the essay is to describe and critically analyse a prescribing event in which I was involved in my nursing practice. The focus is on providing an evidence-based rationale of the prescribing event.Confidentiality StatementAs a student district nurse, Mary Brown is allowed access to the records of the client in this case, research subjects and operational business information. Information which is directly related to the client and may include paper records or oral communication is identified as strictly confidential. Thus, Mary Brown is limited to the minimum amount of confidential information that is required to accomplish the intended purpose of the prescribing event. Description of the Prescribing Event and Analysis of the Situation The student district nurse received a referral from the G.P. that Mrs D has a wound on the left sheen, is bed bound and needs wound assessment and treatment. The nature of the prescribing event is anticipated because I knew beforehand the reason for visiting the client. Except the student as an active participant in the event, other participants present were practice teacher, patient, and patient’s husband. The case is represented by a 70-year-old, bed bound female, with superficial wound to left sheen. Although the skin around the wound has been identified as extremely dry and fragile, the student nurse has also recognised it is well creamed. Upon assessing the client, no other broken areas have been noticed. Patient is using pads for incontinence, gets carers 4 times a day, has hospital bed and mattress, cushion and a hoist. According to patient’s husband, she scratched the wound’s area and it broke. In the process of examining the holistic needs of the client, the student has considered the history of the present complaint (Marcum et al., 2010). This included conducting OPQRSTU mnemonic by exploring pain history checklist, such as onset of pain, palliative factors for pain, quality of pain, region of body or area affected, severity of pain, timing of pain, and how it affects ‘U’ in patient’s daily life. The student has clearly differentiated that patient’s complaint is simply a wound rather than a lesion (Tjia et al., 2012). Moreover, the student has thoroughly explored patient’s past medical history, family history and social history by relying on the cooperation of patient’s husband. Specific question were asked in order to determine patient’s susceptibility to chronic pain and injury. Patient’s exposure to hazards has been determined is minimal considering that the bed bound woman is a non-smoker (Marcum et al., 2010). In this case, the student nurse has decided to prescribe 50-50 Paraffin cream. As part of the medication assessment in the prescribing event, the student asked patient for allergies. However, no allergies were mentioned by client at that point. Other aspects of considering patient’s holistic needs included clinical investigations and physical examination. The student measured patient’s temperature and took a swab for microbiological analysis (Bradley et al., 2007). The physical examination involved careful physical assessment of the wound and wo und’s area. Decision Making and Actions Taken P. and Tissue Viability Nurse referral has not been indicated because the student nurse has confirmed that the diagnosis is clear and does not need referral. This means that there are no any severe aspects related to patient’s diagnosis. In the decision making process of the student district nurse, certain considerations have been made in an attempt to reach a relevant prescribing decision (Bradley et al., 2007). By concluding that patient’s wound is simple and lacks any signs of severity, the student concluded that the selection of a primary dressing and Allevyn Gentle Border as a secondary dressing is justified because it is evidence-based (Junqueira and Carneiro, 2005). Patient expectations for a fast recovery of the wound have been thoroughly considered by the nurse while making that particular decision for administering specific types of dressings. It is important to note that the decision of the nurse to prescribe a primary dressing and Allevyn Gentle Border as a second dressing is reasonable considering the wound’s condition which has been determined after professional assessment and careful physical examination (Guarnera et al., 2007). The primary dressing that was prescribed for patient has been indicated as a paraffin gauze dressing. It has important features, such as soft paraffin base, comprehensive size range, and sterile leno weave presentation. The major benefit of the prescribed primary dressing is that it can soothe and protect the wound as well as open up the passage of viscous exudates, which can take place into the prescribed secondary dressing (Chaby et al., 2007). The fact that the prescribed primary dressing is not medicated shows that it can be ideally used with a topical antiseptic of choice. It can be indicated that the mnemonic EASE has been applied in the decision making process of the prescribing event. The product has been identified as rather effective, as all products from the Allevyn Gentle Border range have been especially designed for individuals with fragile and extremely sensitive skin (Chaby et al., 2007). This type of dressing has a soft silicone gel adhesive, which makes it a convenient option for patient’s condition considering the capacity of the dressing to minimise trauma to the wound when the dressing should be changed. Moreover, this contributes to avoiding patient pain and ensuring adequate care (Guarnera et al., 2007). The effectiveness of the prescribed dressing is evident at its triple-action technology, which contributes to maintaining optimal balance in fluid while the wound is being healed. The choice of Allevyn Gentle Border as a secondary dressing is an appropriate decision made by the district nurse because the dressing provides optimal comfort to patient and it is easy to be applied and removed. The product is suitable for this patient, as no allergies have been reported during the initial assessment conducted by the student (Chaby et al., 2007). In addition, the use of the prescribed secondary dressing is completely safe, as patient can even take shower without any problem given that the dressing is shower-proof. The prescription is cost-effective, as a box of 10 Allevyn Gentle Border dressings (7.5 cm x 7.5 cm size) costs approximately ?22.44, and a box of the same type of dressings (10 cm x 10 cm size) is approximately ?29.99 (Hurd et al., 2009). In a research by Hurd et al. (2009), the focus has been on presenting sufficient evidence of the effectiveness of Allevyn Gentle Border. The authors of the research based their evaluation on a multi-centre clinical assessment, which was conducted in 2008. One of the most important conclusions provided by researchers was that this type of dressing was suitable for the specific wound type treated in almost 95% of patients who participated in the study (Chaby et al., 2007). It has been emphasised that patients’ wounds had healed prior to the end of the specified study period. There was substantial evidence indicating a reduction in wound area and depth upon presenting the final assessment of patients. Moreover, there was significant evidence of a reduction in the precise level of exudates in the wound, which applied to the period between baseline and final assessment (Hurd et al., 2009). There was also a visible reduction in the median percentage of devitalised tissue upon conclu ding the final assessment of patients. In order to assess the appropriateness of the prescribed dressing, the student district nurse demonstrated the initial consideration that the process of prescribing wound products cannot occur generically. The nurse has determined that this type of dressing is appropriate to patient’s condition. As presented in research, Allevyn Gentle Border dressing is found to maintain moisture, implying the inability of sticking to the wound (Chaby et al., 2007). The prescribed dressing belongs to the group of hydrocolloids. The qualities of hydrocolloid dressings have been considered by the student in providing an optimal healing environment, insulation and autolytic debridement. In terms of outlining the advantages of this type of dressing, it is essential to note that hydrocolloid dressings are impermeable to bacteria and other contaminants (Guarnera et al., 2007). The most important advantage is that they do not adhere to the wound but to the intact skin near the wound. However, a sign ificant consideration should be given to the fact that hydrocolloid dressings are not recommended for wounds with extremely heavy exudates, or in the presence of infection. The frequency of dressing changes depends on the severity of patient’s wound (Hurd et al., 2009). Yet, it is important to note that the primary dressing should be changed on a daily basis, while the secondary Allevyn Gentle Border dressing should be changed every 3 days (King, 2003). There have not been considerable side effects associated with the use of the prescribed secondary dressing except slight nausea in rare cases. In the process of negotiating a contract, it is essential to note the aspects of concordance and adherence. The student demonstrated a high level of negotiated concordance in the sense that sufficient information was provided to client including possible side effects, the costs of dressing and the impact on lifestyle. In an attempt to promote greater adherence of client to the prescribed treatment, the student district nurse clearly informed client about the two types of dressings that were prescribed, as well as how to use them and their benefits (Bradley et al., 2007). It has been suggested to both client and her husband to record the time of dressing changes, which served as an additional motivating factor to client to monitor the condition of her wound. The nurse demonstrated her competence in conducting effective communication with client considering that she is from the elderly population, which implies a focus on making the prescribed treatment simple (Hurd et al., 2009). Ther efore, the contract between the nurse and client was considered effective in terms of concordance and adherence. Implications for Future Practice This event is quite important for my future practice and learning because it has provided me with a relevant opportunity to apply all essential steps of a prescribing event in practice. Such a practical experience in prescribing has made me more self-confident in the procedures required to indicate a properly conducted prescribing event in the future (Bradley et al., 2007). I would follow the same model of prescribing for any future similar situation, as I find it effective and reliable in bringing an optimal treatment option to client. I have extensively focused on client’s holistic needs, as this is considered fundamental in delivering adequate care and make an informed decision regarding client’s complaint (King, 2003). I am prepared to expand my prescribing experience in the future by actively participating in similar events and acting in accordance with strict nursing and prescribing principles outlined in the field. Reflection The prescribing event provided an opportunity to learn more about the stages of prescribing and making the best possible decision in a similar situation as the one faced by client. However, I am aware that such a decision may differ upon considering the details of another case, with different aspects of complaints. This means that I should be adequately prepared to encounter different prescribing scenarios (Hurd et al., 2009). I have not experience any major problems during this experience. Yet, I have learned a lot about wound care in relation to this incident. The treatment of this condition may be challenging under particular circumstances especially among the elderly population (King, 2003). Self-monitoring and management of wound may be inappropriately done and thus such individuals may need the assistance of a family member or nurse in order to adhere to the schedule outlined in the prescribing event. Conclusion This report provided significant information about a prescribing event in which a student district nurse participated, accompanied by her practice teacher. The prescribing event was based on an incident with a 70-year-old female, who was identified as bed bound due to superficial wound to left sheen. The nurse critically analysed the situation and demonstrated a prescribing decision that a primary dressing should be used as well as Allevyn Gentle Border as a secondary dressing (Hurd et al., 2009). The prescribing decision was adequately justified given that the nurse provided solid evidence of the benefits of using this type of dressing. However, the only limitation considered in this event is that the nurse may not have invested sufficient time to explore the case in detail (Chaby et al., 2007). Despite this limitation, the student expressed an opinion of increased self-confidence that could help her in similar prescribing situations in the future. References Bradley, E., Hynam, B. and Nolan, P. (2007). ‘Nurse Prescribing: Reflections on Safety in Practice’. Social Science & Medicine, vol. 65(3), pp. 599-609. Chaby, G., Senet, P., Vaneau, M. et al. (2007). ‘Dressings for Acute and Chronic Wounds: A Systematic Review’. Archives of Dermatology, vol. 143, pp. 1297-1304. Guarnera, G., Tinelli, G., Abeni, D., Di Pietro, C., Sampogna, F. and Tabolli, S. (2007). ‘Pain and Quality of Life in Patients with Vascular Leg Ulcers: An Italian Multicentre Study’. Journal of Wound Care, vol. 16, pp. 347-351. Hurd, T., Gregory, L., Jones, A. and Brown, S. (2009). ‘A Multi-Centre In-Market Evaluation of Allevyn Gentle Border’. Wounds UK, vol. 5(3), pp. 32-44. Junqueira, L. C. and Carneiro, J. (2005). Basic Histology. Rio de Janeiro, Brazil: Lange. King, B. (2003). ‘Pain at First Dressing Change after Toenail Avulsion 2: Findings and Discussion of the Data Analysis’. Journal of Wound Care, vol. 12, pp. 69-75. Marcum, Z. A., Handler, S. M., Wright, R. and Hanlon, J. T. (2010). ‘Interventions to Improve Suboptimal Prescribing in Nursing Homes: A Narrative Review’. The American Journal of Geriatric Pharmacotherapy, vol. 8(3), pp. 183-200. Tjia, J., Gurwitz, J. H. and Briesacher, B. A. (2012). ‘Challenge of Changing Nursing Home Prescribing Culture’. The American Journal of Geriatric Pharmacotherapy, vol. 10(1), pp. 37-46.

Facebook effects Essay

THE POSITIVE EFFECTS OF FACEBOOK A Keeping in touch with family and friends-Facebook is a great way to keep in touch with your family and friends that live far away with instant messaging and even video chat. Facebook is the perfect environment to stay connected with the status updates, photos, and profile, information it can keep you updated on the happeningof all your close ones. B Making new friends-Facebook makes meeting new people extremely easy due to the facts that it allow you to add to thousands of friends, and acts as a social melting pot of the internet. If you comment on a friends status and one of their friends comment on it maybe you too will strike up your own conversation. This can lead to a great friendship down the road. Those people find it a lot easier to start a conversation with someone over facebook that it real life. So a lot of high school relationships tend to start there. It’s as so a lot of high school relationship tend to start there. It’s as simple as a â€Å"you should text me some time. C Expressing yourself. Facebook makes expressing yourself very simple with status updates. Between showing of your favorite song lyrics to posting pictures of your new outfit. Facebook is the most common way the people express themselves these days. It is a lot harder to feel embarrassment over the internet than in person, so people find it easier to â€Å"event† their feeling on facebook. Claim that it is a worldwide distraction and even obsession that amount to nothing except for significant amounts of the time wasted there is even a group that is trying to stunt the influence. THE NEGATIVE EFFECTS OF FACEBOOK A Cyber bullying-on Facebook is very easy to cyber bullies to thrive. They can harras and/or gang up one person even easier than they could in a school environment. There aren’t moderators that go around monitoring what people say to each other. Anything can be said. There are also a relatively small amount of parents that have facebook accounts and keep up with their children. More than once we witnessed this form of bullying, whether it be about race appearance, intelligence. B Stalker friendly-Facebook is very stalker friendly website the eoretically, someone that you don’t even know can say that they go to your school, add you and get all of your information this way include your phone number, house address and locations you visit frequently. Not to mention the fact that they will be able to go through all of your pictures and get to know you completely without you ever knowing. This is a scary thought but it is a real issue. Social networking site have several types of users the stalker, the smooth talker, the quiet type the narcissist, Mr, Mrs. Friendly, the games, and the bully are just a few names that I use to describe some of them when using facebookas any type of social networking site one should always be aware. C Distraction- At the end of the day you may have seen your cousin’s new outfit and talked to your sister who is in college, but you still haven’t really accomplished anything in the hour that you were on. Critics of facebook claim that it is a worldwide distraction and even obsession that amount to nothing except for significant amount to nothing of the time wasted. There is even a group that is trying to stunt the influence of facebook.

Issues Faced by Oreedoo Telecommunications Essay

Issues Faced by Oreedoo Telecommunications - Essay Example This paper illustrates that although being one of the largest organizations in its domestic marketplace, Oreedoo Telecommunications is not the biggest market shareholder. The biggest competitor of Oreedo is Omantel. Omantel is also one of the most influential companies in its concerned marketplace. It has set up connections with various influential people and already developed a considerable customer base. Apart from competition, Oreedoo is also facing other challenges related to the regulations of the market and internal problems associated with their talent and employee management. Oreedoo is finding it hard to manage their human resource elements as the employee base is not steady and the employee turnover rate is high. Furthermore, although Oreedoo has acquired the resources for pursuing their strategic objectives, limited employee base in causing barriers to the process. As observed in the given case study of Oreedoo Telecommunications, the company is trying to establish itself in the communications industry of Oman but is facing some critical problems in doing so. The first issue noted was the immense competition faced by the established player such as Omantel. Being one of the early entrants in the communications segment of Oman, Omantel has been able to acquire a large consumer base and have also established relationships with influential and well-positioned individuals. This also focuses on another critical barrier for Oreedoo Telecommunications which is the underdeveloped legal and regulatory structure of the communications segment of Oman. Because of limited regulatory functions in the industry, the manipulation of the legal framework is high. It can be mentioned here that the telecommunications industry of Oman is yet underdeveloped and does not have an appropriate governing body.

Case Study Example | Topics and Well Written Essays - 750 words - 18

Case Study Example nt of employees will be done purely on the basis of merit and the management skills in case of leadership positions.For the role of supervisors, the fittest candidate would be one who has the technical knowledge to guide the team as well as have good interpersonal communication skills for managing the people at work.Instead of a one-day training program, the new policy has the provisions of conducting a three day induction program that provides a detailed insight of the work and initial introduction with the existing employees. The company aims to return value to their employees who are willing to add value to the organization. The company believes in providing the best remuneration package in the industry as per the best standards (Armstrong 2006). This is done through competitive fixation of wages for the employees. Apart from the compensation packages, there are several allowances and perquisites that are offered to the employees.The company also believes in providing health benef its and taking care of the medical needs of the employees and their families. The company believes in equal and fair opportunities for both men and women at workplace. The new policy proposes that women should have equal representations as compared to men in the role of supervisors. This would also create fair and transparent communication practices in the workplace. The senior employees and the managers would engage into period communication and take feedbacks from the operational staffs in the process. This would ensure total involvement of the employees and reduce the chances of any communication gap in the process.The company disapproves the collective bargaining agreement between the employees and the union. The following suggestion for improvement could be provided to the human resource manager of FVI as the past recruitments have resulted in a failure rate of 40% amongst the number of candidates who were recruited. In the past, the supervisors were selected on the basis of their

Africa Article Example | Topics and Well Written Essays - 250 words - 1

Africa - Article Example Because of this attacks and wars on the three states, thousands of people evacuated and left their home for their safety. It is very sad to know that million miles away from us, there have been a lot of killings happening and a lot people here didn’t even knew it happened. The attack in Teludi caused hundreds of lives killed. I feel the fear of the people who left their homes to survive. The children left school, and the parents left their work. It is very depressing to know that these families can no longer enjoy the peaceful lives they’ve lived before because of the attacks. They have left their homes and everything they invested unwillingly to make sure that they will be safe. They have been affected by the political clashes of their state. They had no choice but to leave everything behind to be able to ensure that they will not be affected by the attacks anymore. I cannot stop but hope that the war will soon be over for these families to be able to go back to their normal

Oliver Stone films representing the war Research Paper

Oliver Stone films representing the war - Research Paper Example 1. JFK: This film portrays the events leading to the unfortunate assassination of President Kennedy. It is assumed that this film is based on two books from other authors exploring the same issue. But while the books attracted acclaim, Stone’s JFK instantly got slathered with harsh criticism. Furious historians and critics argued that Stone’s carefree attitude with important historical facts contributed to creation of a highly twisted picture. However, the way JFK later gained confidence and amassed many Academy nominations raises embarrassing questions about the angry criticism published in American newspapers upon the movie’s release. The way Jim Garrison in JFK investigates the assassination from a completely different perspective implying an infamous scheme within the government responsible for Kennedy’s death actually ended up interesting people far more than any book ever did written on the same subject. In fact, the magnitude of excitement felt by people who read books is dwarfed by the magnitude of thrilling suspense experienced by people who viewed the movie, in reference to how the picture reveals different ways by which powerful people use authority to manipulate events (Rendall). The fact that movies can speak louder than words is made emphatic by the way historical events are intelligently portrayed in JFK.

Journal entry #8 Essay Example | Topics and Well Written Essays - 250 words

Journal entry #8 - Essay Example tween the target language and the learners first language and the other sequenced according to increasing linguistic complexity of target language items† (1984, p. 691). A discussion on the syllabus design based on disparities between L1 and L2 structures were subsequently presented where the author identified that the most difficult phase was learning crucial elements in the target language that were absolutely absent in the student’s native language. Therefore, various guidelines and contributions were presented for syllabus design and proposed development on the complexity of the second language was appropriately delved into. Accordingly, the author noted that â€Å"recent findings from interlanguage research suggest several ways in which attention to certain aspects of traditional approaches to syllabus design-specifically, L1 transfer and L2 complexity-can be used in selecting, sequencing, and grading items for the syllabus† (Pica, 1984, p. 700). The article is most useful for teachers in the development and design of effective syllabus considering disparities and complexities in interlanguage instructions and learning. Through the guidelines provided in the discourse for syllabus design from the noted cross-linguistic research, educators are illumined on instructional approaches and methods that would facilitate teaching a second language more

Journal writting ( refer to the attachment) Essay

Journal writting ( refer to the attachment) - Essay Example However, because there was no distinction between ‘work’ time and ‘pleasure’ time, the concept of ‘leisure’ was not introduced until the rise of the city-states of Greece and Rome. Before the age of the Industrial Revolution, ‘leisure’ took the form of education and introspection as it had developed within Greece’s male elite. With industry, a change took place where ‘work’ time was defined, designating non-work time as ‘leisure’. While this worked for a while, women, because they were usually occupied within the home, had no defined period for leisure. As people, men and women, developed their ideas of leisure activities, the cost of leisure began to rise, but could not keep pace with the cost of living. Today, our concepts of leisure involve a great deal of expense, forcing us to continue to work hard during our ‘off’ hours just to keep up with the pace of technology. As a result, leisure is again becoming a missing element of society. While our available time for leisure activities continues to decrease with the increase in the cost of our toys and the decrease in our wages as compared to our living expenses, there is a significant case for the preservation of leisure time. As we struggle to define ourselves, in terms of the I, which is the way we think about ourselves, and the me, which is the way we feel others think about us, we develop a sense of self-esteem, how we feel about who we are (Bolender, 2005). This concept of ourselves is balanced by our realistic idea of ourselves, our ideal interpretation of ourselves, our idea of what we ought to be and our idea of what we don’t want to be. These concepts are all necessarily formed as we interact with others within a free environment in which we can be just who we are rather than attempting to fill some concept of what we should be as in the workplace or other environment. At the same time, how we feel about ourselves, self-esteem, is

My Six Millennium Development Goals Essay Example | Topics and Well Written Essays - 1500 words

My Six Millennium Development Goals - Essay Example While the world most powerful countries boost of their economic achievement, some communities in developing nations lavish in extreme poverty. The stories about people living in extreme poverty are not only sickening but also heartbreaking. It is arguable that when a person lives in poverty, he or she is not able to acquire other necessities such as education, good healthcare among others. The World Bank and the UN have indicated that they have made incredible work in ameliorating the poverty scourge. If I were to assign a letter grade to this specific goal, I would give it an A. This is due to the fact that the United Nations shows efforts to eradicate poverty irrespective of the fierce financial crisis. The target for the extreme poverty MDG is to reduce the current prevalence by half. The UN report shows that many communities leaving under extreme poverty lacked essential needs such as water, food, and shelter. The aforementioned needs are critical to human existence. The progress ive report indicates that the project would meet its deadline. Liberty activists contend that extreme poverty is an indication of deprived rights. Most governments are part of UN accord, which advocates for human liberty. Hunger hampers social and economic development because it influences the ability of an individual to contribute towards nation building. This MDG is critical to the future of the world because the liberty that the society claims to enjoy is evident through social interactions.... The aforementioned needs are critical to human existence. The progressive report indicates that the project would meet its deadline. Liberty activists contend that extreme poverty is an indication of deprived rights. Most governments are part of UN accord, which advocates for human liberty. Target 1 B/ Fight against Hunger Hunger hampers social and economic development because it influences the ability of an individual to contribute towards nation building. This MDG is critical to the future of the world because the liberty that the society claims to enjoy is evident through social interactions. Social theorist believe that the fabric that holds the society depend on human satisfaction. Unfortunately, hunger influences a person’s contribution to social growth. Factors, which limit individual independence, may attract social delinquency in meeting these needs. For instance, a hungry society may not be able to think beyond a means that would enable it to receive food. This means criminal activities are options that the community can adapt to fight hunger. The grade I would assign United Nations in this goal is A- since fighting hunger with the present financial and climate instabilities is hard. The target of this goal is halve the prevalence rate by 2015. The United Nations and the World Bank have contributed in reducing the prevalence of hunger by initiating projects that will empower the affected communities. The UN and World Bank have collaborated with the respective governments in the affected regions such as Sub Saharan Africa, funding sustainable agricultural projects in order to empower the society. The aim of such project intends to

Alexander the Great from Macedonia Essay Example for Free

Alexander the Great from Macedonia Essay The cuisine of th Middle East has the same similarities as that of the Greeks for many reasons. According to history, Alexander the Great from Macedonia which is also known as Greece of todays world came to the Middle East in the 300 BC. This brought about many Greco influences into the lives of the Middle East people. Moreover, during the Roman Empire, the Greeks brought sweets and fruits to th region. As a matter of fact, there has been a continued trade of spices between the two regions that it has become a the spice center of the world. At the same time, the religion of the Middle east has a dominant role to play in their food traditions. Christianity in particular came from the Greek tradition. In Israel, the cuisine is considered to be international because of the diverse immigrants in the country. These immigrants range from countries like Greece to Turkey to Spain and to North Africa which influenced the way Israelites cook and prepare their food. At the same time, the North African cuisine such as that of Libya, Algeria, Morocco, and Tunisia share similarities with most the Arabic tradition because of the Islamic conquest that happened in the 7th century. Most of their cuisines are influenced by the Arabs and the aboriginal peoples of the the region which are called Berbers. In addition, Egypt has large influence geographically. It is situated in North Africa which carries with it an Arabic tradition and culture. North Africa has always been considered Middle Eastern and Mediterranean in nature because of its geographical location. 4. Four of the most famous food in West Africa are Yassa, Sauce Canny, Diebou Dien, and Yam. The Yassa is made out of chicken or lamb with a citrus or a lime in it as a flavoring. It could also be made with fish or vegetables. The saucy Canny is made out of onions, garlics, and shallots which is mainly used as an accompaniment to may of West Africas dishes. The Deibou Dien is composed of fresh and dried fish with onions and tomatoes. It also has as many vegetables as possible such as an eggplant, a manioc, turnips, white radish, cabbage, and carrots. In East Africa, the common foods are Niker Kebboh and Alecha. Niter Kebboh is made up of butter with spices like ginger, garlic, and cinnamon. Alecha on one hand is a stew made of chicken or beef or other kinds of meat. It is accompanied with bread. It is usually dipped into the spicy dishes and once its already soaked up the it is lifted into the mouth. 5.

Legalize Marijuana Essay Example for Free

Legalize Marijuana Essay Marijuana has been vilified in America over the past 70+ years. Despite its many practical uses, medicinal and industrial, our Federal government insists on maintaining the status quo that the growth, possession and use of marijuana is criminal despite the evidence that the legalization of marijuana would have a positive influence on America. In this paper I will discuss the history of marijuana, the industrial uses of hemp, the prohibition of marijuana, the economic impact prohibition has on America, the effects of marijuana use on the mind and the body, marijuana for medical use, and how legalization of marijuana would have a positive influence on America. Although I support the legalization of marijuana I do not support the legalization of other Schedule I drugs, therefore this paper is not about the legalization of all drugs. Marijuana, as most people commonly know it, is really a plant called hemp, or cannabis sativa. There are other plants called hemp, but cannabis hemp is the most useful of these plants. Hemp is any durable plant used since prehistory for many purposes, and cannabis is the most durable of the hemp plants. The cannabis plant also produces three very important products that other plants do not, seed, pulp, and medicine. The cannabis sativa plant grows as weed and cultivated plant all over the world in a variety of climates and soils. Marijuana has been used throughout history; in 6000 B.C. cannabis seeds were used as food in China; in 4000 B.C. the Chinese used textiles made of hemp; the first recorded use of cannabis as medicine in China was in 2727 B.C.; and in 1500 B.C. the Chinese cultivated Cannabis for food and fiber. This time line goes on and on right through today. It is thought that hemp was first brought to the New World in 1545 by the Spanish; it was introduced in Jamestown by the English in 1611 where it became a major commercial crop alongside tobacco and was grown as a source of fiber. Our forefathers grew hemp; in fact it was the principal crop at Mount Vernon and it was a secondary crop at Monticello. There are recorded notes made by George Washington regarding the cultivation and harvesting of hemp. These hemp crops of course were grown for industrial use only and there is no indication that our forefathers were using their crops recreationally. Today the hemp grown for industrial purposes have extremely low levels of THC Delta 9-tetrahydrocannabinol delta 9-THC, the active component in cannabis therefore it is impossible to get high from such hemp grown for industrial use. During the Colonial Era Americans were legally bound to grow hemp. During the Second World War the federal government subsidized hemp and US farmers grew about a million acres of hemp as part of that program. Hemp is extraordinary in its diversity. There are over 25,000 different uses for the hemp plant. Because of how quickly hemp can be cultivated it is the Earth’s number one biomass resource. Hemp’s uses include but are certainly not limited to fuel; food, hemp seeds provide an incredible source of protein-not only for people but for birds who seek out hemp seeds which have been mixed with other seeds; paper; textiles, for example canvas, paper, cloth, rope; paint; detergent; varnish; oil; in; medicine; and building materials. Almost any product that can be made from wood, cotton, or petroleum including plastics can be made from hemp. In fact, hemp plastics are biodegradable. Besides its diversity, the practicality of utilizing hemp to its fullest potential is clear. Trees take from 50 to 100 years to grow; hemp’s growth cycle is 120 days. It is estimated that if the hemp pulp paper process reported by the USDA in 1916 were legal today it would soon replace 70% of all wood paper products. Despite all of its proven uses, all of which are beneficial to the planet Earth, the growth of industrial hemp in the United States remains a criminal act thanks to the robotic ravings of our federal government. President and founder of Drug Abuse Resistance Education (DARE) Glenn Levant Hemp is marijuana. Philip Perry, special agent in charge of the DEAs Rocky Mountain Division ignorantly states, (Levant 1) the effort to decriminalize hemp is no more than a shallow ruse being advanced by those who seek to legalize marijuana. It should be noted that the selling hemp products are not illegal and in fact the U.S. hemp-products industry does about $125 million in retail sales a year. Although most states had local laws prohibiting marijuana use and possession, it wasn’t until 1937 that the federal government passed the 1937 Marihuana Tax Act. Interestingly, the congressional hearings on marijuana prohibition lasted all of two hours in direct contrast to most congressional hearings on new laws which last for days and days. There were exactly three bodies of testimonies testifying at these hearings. The first was Commissioner Harry Anslinger, the newly named commissioner of the Federal Bureau of Narcotics who happened to be appointed by his uncle-in-law, Andrew Mellon, who was the Secretary of the United States Treasury. Commissioner Anslinger testified on the government’s behalf. Not surprisingly he was working from a text which he had not written himself but which had been written for him by a New Orleans District Attorney. Reading directly from this text Commissioner Anslinger told the Congressmen at the hearings, Marihuana is an addictive drug which produces in its user’s insanity, criminality, and death. That was the Commissioner’s brilliantly insightful government testimony to support the marijuana prohibition. The second bodies of testimony to testify at this congressional hearing were industrial spokesmen. The first of these spokesmen was, believe it or not, a man representing the rope industry. This industry representative testified that it was cheaper to import from the Far East the hemp needed to make ropes and therefore the United States no longer needed to grow any more hemp to make rope. Five years later, in 1942, the United States was cut off from its sources of hemp in the Far East and, since we needed a lot of hemp to outfit our ships with rope for World War II, the Federal Government went into the business of growing hemp on gigantic farms throughout the Midwest and the South. The paint and varnish spokesmen didn’t seem to care either which way. The only industrial spokesperson who objected to the Marijuana Tax Act at all was the birdseed representative who sang the praises of hemp seeds for the birds’ coats. Based on this objection the birdseed industry got an exemption from the Marijuana Tax Act for denatured seeds. â€Å"The third body of testimony was two representatives of the medical field. The first testimony came from a pharmacologist who claimed that he had injected the active ingredient in marihuana into the brains of 300 dogs, two of which died. When asked by the Congressmen if he choose dogs for the similarity of their reactions to that of humans the answer of the Pharmacologist was, I wouldnt know, I am not a dog psychologist. The active ingredient in marijuana was first synthesized in a laboratory in Holland after World War II therefore it is unknown to this day what this pharmacologist injected into the dogs. The second testimony on behalf of the medical field came from the Chief Counsel to the American Medical Association, Dr. William C. Woodward. Dr. Woodward was the hearing to testify at the request of the American Medical Association. His exact quote to the congressmen was, The American Medical Association knows of no evidence that marihuana is a dangerous drug. to which one of the Congressmen said, Doctor, if you cant say something good about what we are trying to do, why dont you go home? Remember, this testimony came from the Chief Counsel of the esteemed American Medical Association. It should be no surprise that the bill passed. The act did not itself criminalize the possession or usage of marijuana but instead levied a tax of approximately one dollar on anyone who dealt commercially in marijuana. The penalty provisions for violators of the proper procedures could result in a fine of up to $2000 and five years imprisonment. The intended result and indeed, the result of the 1937 Marihuana Tax Act was to effectively make it too risky for anyone to deal in the substance. During the war years the Bureau chose to concentrate on opiates and abandoned responsibility for most marijuana law enforcement to the states. In the post-war years, however, there was found to be a significant increase in narcotic drug abuse and the public began to be concerned with the spread of narcotic addiction, particularly among young persons. Congressional furor was aroused by the assertion that the use of marihuana inevitably led to the use of these harder drugs, particularly heroin. In 1951 Congress passed the Boggs Act, increasing penalties for all drug violators. It was at this time, for the first time in federal drug legislation, that marijuana and the narcotic drugs were lumped together, since the Act provided uniform penalties for the Narcotic Drugs Import and Export Act Boggs Act, ibid. and the Marihuana Tax Act. The states followed the federal lead. Then, in 1956, Congress passed the Narcotic Control Act, escalating the penalties still further. Once again the individual states followed suit. The current Controlled Substances Act (CSA), Title II of the Comprehensive Drug Abuse Prevention and Control Act of 1970 is a consolidation of numerous previous laws regulating the manufacture and distribution of narcotics, stimulants, depressants, hallucinogens, anabolic steroids, and chemicals used in the illicit production of controlled substances. The CSA places all substances that are regulated under existing federal law into one of five schedules. This placement is based upon the substances medicinal value, harmfulness, and potential for abuse or addiction. Schedule I am reserved for the most dangerous drugs that have no recognized medical use, and, of course, is the current classification of marijuana. Public opinion on the medical value of marijuana has been sharply divided. Some dismiss medical marijuana as a hoax that exploits our natural compassion for the sick; others claim it is a uniquely soothing medicine that has been withheld from patients through regulations based on false claims. Proponents of both views cite scientific evidence to support their views and have expressed those views at the ballot box in recent state elections. In January 1997, the White House Office of National Drug Control Policy (ONDCP) asked the Institute of Medicine to conduct a review of the scientific evidence to assess the potential health benefits and risks of marijuana and its constituent cannabinoids. That review began in August 1997 and culminates with the report Marijuana and Medicine, Assessing the Science Base from the Institute of Medicine. This study was supported under Contract No. DC7C02 from the Executive Office of the President, Office of National Drug Control Policy. This report summarizes and analyzes what is known about the medical use of marijuana; it emphasizes evidence-based medicine derived from knowledge and experience informed by rigorous scientific analysis, as opposed to belief-based medicine derived from judgment, intuition, and beliefs untested by rigorous science. After their nearly two-year review, the investigators affirmed Scientific data indicate the potential therapeutic value of cannabinoid drugs for pain relief, control of nausea and vomiting, and appetite stimulation. Except for the harms associated with smoking, the adverse effects of marijuana use are within the range tolerated for other medications. However, the authors noted that cannabis inhalation would be advantageous in the treatment of some diseases, and that marijuanas short- term medical benefits outweigh any smoking-related harms for some patients. A most comprehensive and informative report on this subject is, The Budgetary Implications of Marijuana Prohibition by Jeffrey A. Miron, Visiting Professor of Economics, Department of Economics, Harvard University, which was published in June, 2005. This paper concludes. Replacing marijuana prohibition with a system of legal regulation would save approximately $7.7 billion in government expenditures on prohibition enforcement $2.4 billion at the federal level and $5.3 billion at the state and local levels. Revenue from taxation of marijuana sales would range from $2.4 billion per year if marijuana were taxed like ordinary consumer goods to $6.2 billion if it were taxed like alcohol or tobacco. These impacts are considerable, according to the Marijuana Policy Project in Washington, D.C. For example, $14 billion in annual combined annual savings and revenues would cover the securing of all loose nukes in the former Soviet Union estimated by former Assistant Secretary of Defense Lawrence Korb at $30 billion in less than three years. Just one years savings would cover the full cost of anti-terrorism port security measures required by the Maritime Transportation Security Act of 2002. The Coast Guard has estimated these costs, covering 3,150 port facilities and 9,200 vessels, at $7.3 billion total. A further comprehensive study which reports and analyzes national arrest data between 1995 and 2002 is, Crimes of Indiscretion, Marijuana Arrests in the United States, compiled by Jon Gettman, PhD, published by The NORML Foundation in 2005. There are many reasons for marijuana wanting to be legal. It isn’t just the stoners and illegal distributers that want it, but also the people that use it for medicinal use. In my perspective that’s the reasoning for the bill not being passed. Just people seeing that one word marijuana, they take one look and think it’s just a group of pot heads that want to be able to smoke it legally. It can help many people probably everyone in the world if you think about it properly. Works Cited 1. Cruz, Veronica. â€Å"Gunmen Get Medical Pot from Home on NE Side†. Arizona Daily Star. 20 March, 2012: A1 A5. 2. Kurwa, Nishat. â€Å"Federal Agents Bust Marijuana School ‘Oaksterdam.’’’ NPR. NPR, 03 Apr. 2012. Web. 12 Apr. 2012. http://www.npr.org/2012/04/03/149937087/federal-agents-bust-marijuana-school-oaksterdam. 3. Legalizing Marijuana. Legalizing Marijuana. Web. 09 May 2012. http://www.uri.edu/personal/atro6990/. 4. Legalization of Marijuana. Legalize Marijuana, Legal Weed, Marijuana Facts. Web. 09 May 2012. http://legalizationofmarijuana.com/. 5. Schlosser, Eric. Reefer Madness, TheAtlantic: 1994. 6. â€Å"Up In Smoke.† The Economist. The Economist Newspaper, 14 Apr. 2012. Web. 12 Apr. 2012. http://www.economist.com/node/21552609.

Impact of Poor Services on Healthcare Organization

Impact of Poor Services on Healthcare Organization Assessment 4 Issue 1: Effect of Poor services On Reputation of Kindly Residential Care Rest Home Generally, the reputation of an institution, particularly elderly care facilities, is very essential in order to make known to concerned clients and their families how firm the institution is in offering quality health care services. In order for an institution live up to their reputation or even exceed the expectation of the clients and be more competent than other neighboring competitors, series of quality improvement measures are then conducted all year round. The first step or approach in quality improvement is to be able to identify certain factors that have a potential or a likelihood of contributing to the rise and fall of an institution’s reputation. Patient safety Safety for the client is always considered the highest priority and is the topmost factor to consider. Issues such as shortfalls, injury, elderly abuse and the like are indicators that help measure the quality of service rendered by the institution. If and when complaints in relation to these issues start skyrocketing, that is when measures for legislative amendments are called for. When the safety of a resident is at risk in an institution that is reputed to have substandard services and management, the said institution will be subjected to disciplinary action set by the Ministry of Health. Management The essential component of a healthy institution is quality satisfaction derived from both the staff and, most importantly, the customer or client. And the driving force of an institution is the operational team or the management. Any quality of service rendered by the staff and level of client satisfaction would greatly reflect on the management’s performance. Poor management over staff, facility and its services would lose the trust of its staff as well as its clients. Quality assurance The quest for an institution’s outstanding reputation doesn’t happen only once. Over periods of time, a series of audits, surveys, investigations, studies and statistics are continuously conducted to ensure that an institution lives up to its reputation. Quality assurance is there to make sure that the institution still served its purpose. At some point, certain issues within the institution have been overlooked and what has been known to be reported to responsible parties doesn’t seem to reflect the raw evidence that may arise from poor quality assurance. This would then lead people to think otherwise about entrusting themselves with the institution. On Accountability of Private Sectors and Public Sectors Private sectors are at an advantage when it comes to accountability. The public sector accounts more than the private sector, since most legislations and policies governing private institutions are stipulated by the public sector. When poor services are noted from the public sector, consumers or clients tend to rely more on the private sectors due to their extensive services and features. Because the government has minimal or little involvement over private sectors over quality improvement measures, the private sector may have the opportunity to expand the boundaries of their services in order to improve better client outcomes. There is no formal organizational structure compared to the public sector. Therefore, in the event that poor services may arise from Kindly Residential Care Rest Home, it may turn to be more of a challenge in order to gain competency in the health care industry. Stakeholders They are the persons who have a â€Å"stake ‘’ in any organization. They may be called: Internal Stakeholders in the Kindly Residential Care Rest Home, the Internal Stakeholders are the Owners or the Healthcare Providers, the carers, the nurses, and all who work for the well- being of the elderly especially those persons with dementia. The External Stakeholders include the Government and Non- government organizations which contribute their time, treasure and talent to help the Residential Care Rest Homes deliver quality service. â€Å"Quality of Care’’ is a difficult concept to measure particularly within the context of residential aged care, which involves lifestyle issues as much as health issues. One example is the Australian Accreditation Standards having been credited with contributing to improve care. Though they represent only minimum standards of quality, they do not focus on clinical outcomes. Individual facilities might only be assessed against these standards every 3 years; and within these years, much scope for quality variations may go unnoticed. Hence, collecting and analyzing comprehensive clinical data from aged care facility residents constitutes an essential step in the process of monitoring quality environment. Ways to Improve The USA has introduced and continued to refine, a compulsory technioque of assessment within its nursing homes aimed at monitoring quality of care and clinical outcomes. There is a Minimum Data Set/ Resident Assessment Instrument which is a system of forms to be completed at certain intervals to meet a number of purposes such as care planning, case mix funding and quality monitoring. This uses Quality Indicators as a means of implementing quality assurance and improvement within residential aged care. Residential facilities had been subsidized by the Commonwealth Government since 1962, but funding was not regulated. Initiatives relevant to residential care have included a standardized system of assessment (Resident Classification Scales) to determine resident care needs and a formal system of Accreditation to ensure quality service delivery. Because quality of care is a multi – dimensional concept, no single area of assessment can provide an accurate indication of quality. Thus, an effective assessment should contain as many items considered relevant to quality care. Hughes et. al suggested that quality measures should be integrated into routine clinical practice. The Australian Society for Geriatric Medicine described the Residential Classifications Scales as the â€Å"antithesis of a funding system that generates incentives for quality health outcomes.’’ Government –appointed bodies responsible for assessing residential care facilities compliance with standards improved quality of care within residential care facilities. Aged Care Standards and Accreditation Agency was introduced in 1998 that compels residential aged care facilities to seek accreditation for funding. Clark and Bowling (32) suggested that quality of life in residential care could be ascertained by looking at measurable indicators such as general health, functional status, mental health, comfort, emotional wellbeing, privacy, choice and autonomy. When considering quality assessment for residential aged care facilities, indicators of quality should encompass areas of clinical care directly related to residents’ physical health, as well as quality of life and lifestyle-related issues such as activities and family involvement. Issue 2: Quality Management Theories Pareto Analysis This is a simple methodology by which prioritization of potential changes through determining the problems that can be addressed and resolved through making necessary changes. Through this technique, the organization can make prioritization according to the individual alteration that could improve the scenario. This quality management tool utilizes the Pareto Principle or the 80:20 rules. This rule utilizes the concept of 20 percent cause that could produce to 80 percent outcome. The Kindly Residential Care Rest Home will use the following approach while taking into consideration the principles of Pareto Analysis to achieve the best practice in healthcare services of the said organization. Problem Identification and List it First, the problems and potential threats are listed down. In this step, possible inputs from clients and members of the Kindly Residential Care Rest Home (KRCRH), and conduct surveys to identify the existing problems in the organization. The root cause of problems are identified In this stage, methods are utilized that warrants the team to identify the root causes of threats and problems. Score Problems In the third step, the organization prioritizes the problems according to its severity or effect on the healthcare practices of KRCRH. Problems are grouped according to their root cause. The identified problems are put in to a group according to their root causes. Add up Scores In this step, scores are added up and identify which of the group has the highest and lowest score. Through this, prioritization is according to scores are done. Take Action In the final step, KRCRH will take actions in addressing the highest priority according to the group or problem that got the highest score. William Edwards Deming Dr. William Edwards Deming proposed the plan-do-check-act, also known as PDCA. It is a four step methodology by which used by the organization to control and improve the services and product of an organization. Kindly Residential Care Rest Home will also make use of this kind strategy to improve the healthcare services of the healthcare organization. The end result of this would be a high quality of services by the facility to the residents and staff of the organization. The following are the Steps of PDCA that the facility will make use: PLAN Objectives and processes are established which are necessary to deliver the outcome in to the expected results. The KRCRH will have a clear view of their target and their goals in achieving their proposed target in this initial phase. DO The plans from the initial phase are implemented in the second step. Data collection is also vital in this phase because the data collected will be used in the later stage of the process. CHECK The KRCRH will do evaluation of the data gathered during the DO stage. These will be charted and analyzed by the facility to identify which needs to improved and which are well in the health care services of the KRCRH facility. ACT Corrective actions are done in phase. The differences between the actual and planned results are analyzed and the root causes are determined. The corrective actions are implemented to achieve the planned outcome of the KRCRH. Issue 3: Quality Management Tools Total Quality Management Behind success of Kindly Residential Care Rest Home are the people who are hand in hand managing an organization, determined to make change for rendering the best of its healthcare services. Through years that Kindly Residential Care Rest Home offers quality of care to its residents and proves its Excellency by garnering prestigious awards, positive feedback and unending trust from stakeholders, family and community its success does not end instead continuity of more complete, comprehensive and structural way of management by enhancement of strategies to improve the quality of services is their big secret towards success or the so called â€Å"total quality management†. Kindly Residential Care Rest Home utilizes total quality management to ensure that giving the quality of care for their residents will not be compromised which can lead to poor health outcomes and downfall of the organization due to improper management. Using the total quality management Kindly Residential Care Rest Home first identify the problem and plan what to do. Second is to implement the solution then evaluate or check if it resolves the problem. And lastly integrate the solution if it works upon further evaluation. As a result Kindly Residential Care Rest Home identified the following problems and able to resolve and improve its quality of service. Falls Risk – most of the common problem that arises among the elderly due to physical restriction like inability to walk or unsteady gait, mental incapacity, side effect of a drug, and in relation to disease condition like poor vision, etc. To prevent this happen solutions are the following: use of sensor mat, call bell, mattress, assistive devices (walker and gutter) , side rails (as necessary and with GP`s order) UTI outbreak – another problem that is commonly and easily acquired by elderly due to low intake of water and poor hygiene. To address this problem the following should be implemented like hand washing, proper hygiene, use of PPE, hand sanitizer to each room and even corridor, health education or information dissemination (mass production of pamphlets regarding UTI prevention), infection control, and proper waste disposal. Patient satisfaction – one of the most important thing to be prioritize because patients are the ones who receives care and they should be satisfied or even exceed the expectation of the services being rendered to them. To be able to improve the quality of care makes the patient satisfied and happy the following are being implemented to have quarterly auditing of services rendered, quality assurance, suggestion box or feedback forms. Incompetent staff – to give a quality of care means to have enough knowledge and skills to handle the patients and assist them according to their needs. Incompetent staff is another problem identified that contribute in poor healthcare delivery service and patient`s injury. For example clinical error, and negative feedback. To address this problem the following are being implemented like comprehensive recruitment and selection, trainings and seminars, disciplinary action, continuous evaluation and staff appraisal. Lean Management Lean Management is all about encouraging everyone in the facilities from the top management down to the staff to be involved in helping to participate in the improvement of quality care, and reducing errors. First, you have to identify the problem and acknowledge that the problem exists and why it is a problem, willingness to change and you can now find ways on how to solve that problem. In Kindly Residential Rest home we value our residents, respect our residents and continue to provide quality of care. We have to understand the voice of our clients, where they coming from, and made sure to meet their needs and put into action. The most important thing in lean for healthcare organization is that the errors and mistakes are being corrected nor improve, the amount of time taken is being valued, productivity increases, and so it is easy for the staff to work easier by eliminating those waste that can provide good quality of care and productivity of the staff. Here are some of the common Errors: Clinical Communication – In electronic patient record, if there is any laboratory test results needed instead of waiting for a week wherein referral needed from the attending physician of the patient and then sending back the result from the physician, the system is being made to remove any unnecessary stages instead laboratory people sends electronic results so he can access right away and evaluate the result. So, it saves time and effort of the patient from travelling. Waiting time/ Getting Appointment – Appointment System is an agreement to meet with the physician at a specific time and day and it is used also to control the demand and the problem is on the mismatch on the capacity of the patients and the physician. In order to avoid this problem the system must be monitored or may provide different type of consultation to accommodate everyone. In result, the patient is being examined on the day she wanted to be seen, less stressed for the staff. Overproducing – spending so much time on something that is not important for the patient Defects – wasted time and effort for the inspection of something that has been already done or inspected In KRRH we value our residents the most, we have to eliminate those wastes and focus to what is important to our client and be able to maintain the quality of work and our commitment to our profession and to the residents as well. Issue 4: Continuous Improvement System It is important to maintain a continuous improvement system for delivery of service to geriatrics. Quality management is one way to improve the system and it is composed of costumer focused organization, leadership, involvement of people, process approach, system approach to management, continual improvement, decision making, and mutually beneficial supplier relationships. In order to perform quality improvement an organization must consists of team that has a deep understanding of an area that requires enhancement. Organization like the Kindly Residential Rest Home is determined to continue finding solutions for the present problems as well in the future that may arise. By continuous improvement of the system there will be a positive result that will lead to a better healthcare service it will ensure the high standard of care that is cost effective and accessible to all. Organization must be sensitive to the needs of the patients and therefore must understand and ensure that there will be a plan of action to meet those needs. This is the result when an organization is costumer focused. Secondly is the Leadership, this is the action of leading a group of people and the leader should know how to unite people that will be involved in achieving the organization’s goals. Thirdly, is the involvement of the people in the organization at any level must do their part in their full capabilities in order to have a successful outcome that can be used for the benefit of the organization. Continuous improvement is necessary because there is no permanent in this world, even the facility in some point changes. Given an example is the technology; people depend on computers and this help in many ways like documentation, auditing and research. Many facilities depend on computer and internet because they make the job easier and efficient. Trainings and seminars a re also another way of improving the system. Developing and enhancing the skills of employees will lead to better healthcare delivery. A well knowledgeable and trained staffs has so much to offer that will benefit not only the clients but also the organization. They will be more confident as well as an important member of the facility. The residents will be satisfied with the care that they are getting from the healthcare providers and as the result they intend to stay longer. The facility will gain a good reputation and the business will be successful. This will attract more people to invest in the health care industry. By frequent assessment and analysis of the problem or changes there will be an ideal plan of action. Continuous improvement in an organization is part of duties and responsibilities of management. To achieve highest performance and success adapting to changes is essential. There is no such thing as constant especially when it comes in dealing with lives of people. Different approaches must be applied depending on the person’s character, behaviour or needs.

Courage in Little Women and Treasure Island Essay -- Literary Analysis

The dictionary definition of courage is bravery or boldness. In the set texts of Little Women and Treasure Island, courage is defined through the interaction of the characters, the situation and their reactions to it. Thus, there are different aspects of courage explored throughout the texts resulting in either in physical or psychological pain or a mixture to the characters. In this essay, I will analysis the method that each author employs to inform the reader of courage, discuss some aspects of courage explored in the texts and look at how courage differs between the genders. Alcott uses characterisation to display courage. She builds the characters over a period through their words, actions and appearance in conjunction with other characters comments and an omniscient authorial voice (Lukens, 2003). The character of Beth has a shy manner and timid voice, staying at home and who admits to being afraid of people. She is ‘dear’ to other characters and the author tells the reader her pet name is mouse. Yet this character shows courage by thanking Mr Laurence, who frightens her, for her piano causing Meg to exclaim that ‘the world is coming to an end’ (Little Women p.63) Alcott enhances this action through intertextuality to Pilgrims Progress where Mr Laurence is one of the biggest lions guarding the Palace Beautiful. Beth is the foil for the main protagonist, Jo for whom this behaviour is normal as evidence by her statement of Mr Laurence ‘I’m sure now that I shouldn’t be afraid of him’ (Little Women p.52 ). This illustrates that there are different levels of courage dependant on the characteristics of the character. Stevenson (2009) admits in his essay about his first novel that he does not use psychology and fine writing wh... ... (eds), Children’s Literature Classic Text and Contemporary Trends, Basingstoke, Palgrave Macmillan in association with Open University Loxley, D. (2009) ‘Slaves to adventure: The Pure Story of Treasure Island’ in Montgomery H and Watson N (eds), Children’s Literature Classic Text and Contemporary Trends, Basingstoke, Palgrave Macmillan in association with Open University Lukens, R. (2003) ‘Character’, A critical Handbook of Children’s Literature, Boston (USA), Ablong Reynolds (2009), http://learn.open.ac.uk/file.php/6764/!via/resourcepage/59898199/6764/moddata/resourcepage/ea300_dvd1_Boys_and_girls_reading_19th_century_transcript.doc Stevenson, R. (2009) ‘My first Book: ‘Treasure Island’’, in Montgomery H and Watson N (eds), Children’s Literature Classic Text and Contemporary Trends, Basingstoke, Palgrave Macmillan in association with Open University Courage in Little Women and Treasure Island Essay -- Literary Analysis The dictionary definition of courage is bravery or boldness. In the set texts of Little Women and Treasure Island, courage is defined through the interaction of the characters, the situation and their reactions to it. Thus, there are different aspects of courage explored throughout the texts resulting in either in physical or psychological pain or a mixture to the characters. In this essay, I will analysis the method that each author employs to inform the reader of courage, discuss some aspects of courage explored in the texts and look at how courage differs between the genders. Alcott uses characterisation to display courage. She builds the characters over a period through their words, actions and appearance in conjunction with other characters comments and an omniscient authorial voice (Lukens, 2003). The character of Beth has a shy manner and timid voice, staying at home and who admits to being afraid of people. She is ‘dear’ to other characters and the author tells the reader her pet name is mouse. Yet this character shows courage by thanking Mr Laurence, who frightens her, for her piano causing Meg to exclaim that ‘the world is coming to an end’ (Little Women p.63) Alcott enhances this action through intertextuality to Pilgrims Progress where Mr Laurence is one of the biggest lions guarding the Palace Beautiful. Beth is the foil for the main protagonist, Jo for whom this behaviour is normal as evidence by her statement of Mr Laurence ‘I’m sure now that I shouldn’t be afraid of him’ (Little Women p.52 ). This illustrates that there are different levels of courage dependant on the characteristics of the character. Stevenson (2009) admits in his essay about his first novel that he does not use psychology and fine writing wh... ... (eds), Children’s Literature Classic Text and Contemporary Trends, Basingstoke, Palgrave Macmillan in association with Open University Loxley, D. (2009) ‘Slaves to adventure: The Pure Story of Treasure Island’ in Montgomery H and Watson N (eds), Children’s Literature Classic Text and Contemporary Trends, Basingstoke, Palgrave Macmillan in association with Open University Lukens, R. (2003) ‘Character’, A critical Handbook of Children’s Literature, Boston (USA), Ablong Reynolds (2009), http://learn.open.ac.uk/file.php/6764/!via/resourcepage/59898199/6764/moddata/resourcepage/ea300_dvd1_Boys_and_girls_reading_19th_century_transcript.doc Stevenson, R. (2009) ‘My first Book: ‘Treasure Island’’, in Montgomery H and Watson N (eds), Children’s Literature Classic Text and Contemporary Trends, Basingstoke, Palgrave Macmillan in association with Open University

The Human Genome Project :: essays research papers

Marshall, Elizabeth L. The Human Genome Project: Cracking The Code Within Us.   Ã‚  Ã‚  Ã‚  Ã‚  New York, New York: Franklin Watts, 1996. 1-128.   Ã‚  Ã‚  Ã‚  Ã‚  Elizabeth L. Marshall was born in Minneapolis, Minnesota. She grew up in areas of southern California, and in parts of New York City. She lives in Columbus, Ohio, and is currently married and has two daughters. She attended and graduated from the University of Virginia with a B.A. in English. She then graduated from the University of Pittsburgh with a Master of Fine Arts degree in fictional writing. She has worked form several scientific journals and magazines and is a member of the National Association of Science Writers. She has also written several well known books including Conquering Infertility: Medical Challenges and Moral Dilemmas, and High-Tech Harvest.   Ã‚  Ã‚  Ã‚  Ã‚  I chose this book because it seemed like an interesting topic, and because I thought it might help me understand more things about DNA. Someone else who read it said that it had a lot to do with the things we covered in class too so I figured it would be as good a choice as any.   Ã‚  Ã‚  Ã‚  Ã‚  This book is about the amazing task of mapping and showing all the sequences of the thousands and thousands of genes in the human body. The book is split up into nine chapters each of which covers a different aspect of this incredible project. The book tells all about almost every aspect of the project. It tells all about the project and what the point is, what has been accomplished so far, and when they expect it to be finished. According to the introduction the project is actually expected to be finished sometime this year.   Ã‚  Ã‚  Ã‚  Ã‚  The first chapter starts off with the basic structure of DNA and describes how the base pairing of each nucleotide creates each amino acid, which when all put together create a strand of DNA. It also gives an idea of who is working on the project. She lists several major cities where the project is being worked on and then goes on to explain how between all these different teams, who are all working on some different aspect of the project, there are also anywhere from 200 to 400 other smaller teams all around the country working on it. The next chapter is about chromosome 18, and how a slight mistake in it can cause things like mental retardation and deafness, and what they are trying to do to help stop or fix chromosome 18 deletion syndrome.