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Gentle Forest Parker, III
Gentle Forest "Sonny" "Preacher" Parker, III
Gentle Forest "Sonny" "Preacher" Parker, III, was free to fly on Christmas Day, December 25, 2014. He passed away at William S. Middleton Veteran's Hospital in Madison with his fiancé comforting him. He was born July 1, 1947 in Selma, Alabama to the late Gentle Forest and Mary (Phillips) Parker II. He attended school in Alabama, but never graduated. He passed the college entrance exam to enter college where he received an Associate Degree in Behavioral Science.
Sonny was active in the Civil Rights Movement, marching with Dr. Martin Luther King, Jr. He joined the U.S. Army on June 29, 1969 and proudly served as an SPC Army Ranger of the 101st Airborne Division, serving in Vietnam and Africa. He received many medals, including the Bronze Star.
Being fit was very important to Sonny. He called himself a gym rat and worked as a trainer at several health clubs. He was a body builder and was Mr. Madison in the 70's. He held many jobs in his lifetime, working two or three at a time, including Scout Master for Blue Mounds, parole officer, security guard and psych attendant. The job he enjoyed most was working with young men, although, he was also part of two special girls' lives, raising them for five years; Brionna Pledgure and Jaidah Whitely, who called him "Pops". He created his own group home, working with Dane County and the Madison Schools. He also created the ABC Basketball Team and was their Coach Parker. He believed that "you could be whatever you want to be."
Sonny endured many struggles after leaving the service. Through his journaling he voiced that PTSD virtually isolated him. This illness made it difficult to maintain relationships and jobs. He dealt with night terrors, depression and anxiety. With the help and guidance of his group therapy in Ohio with Jimmy and friends, he was able to rise above his demons and find peace.
Sonny is survived by his fiancé, Cheryll Holley and her daughters, Amy (Larry) Franklin and their daughter, Mya Franklin and Tina (J.Davis) Jeremiason and her daughter Teeanna Brisco. He is further survived by Earnestine Parker, and their children, Tanisha Ferran, Juanita Parker, Angie Phillips and Ebon Parker; eight grandchildren; one great-grandchild; a sister, Irelene Parker; a brother, Ernest Parker; and nieces and nephews.
He was preceded in death by his parents; two brothers; and his father-in-law.
A special thank you goes to the VA Hospital Surgical ICU, third floor, and VA Hospital Hospice. You all are such special angels yourselves. XOXOXO.
My Angel, my rose man…We were so blessed to have each other for five years and five months. You are such an amazing man. You made me smile every day. Remember: "Love You" "Together Forever" "See Ya".
A Memorial Service will be at 12 noon on Saturday, January 3 at RYAN FUNERAL HOME, VERONA CHAPEL, 220 Enterprise Drive with Reverend Kurt Billings and Reverend William Badger officiating. Visitation will be on Saturday at the funeral home from 10 a.m. until the time of service. Luncheon at St. James Lutheran Church in Verona will follow the funeral home service. Interment will take place in the summer at Verona Cemetery.


This bull terrier puppy and parent sculpture is the latest in a series of parent-baby sculptures featuring dogs and other animals. One fun aspect of creating sculptures with two animals is that three spirits are captured: each of the animals and also the relationship between them. This sculpture took shape when I decided to create a large version of an earlier sculpture depicting a bull terrier with one black eye in a spike collar. As I set out to form the piece, I thought about the collar and the idea for the sculpture hit me. I would create one big bull terrier standing sturdy in its spike collar and a little bull terrier puppy nestled between the big dog's legs, gazing up with a look of admiration and a too-large collar hanging on its neck. A big collar to fill. I also decided to make the dogs with complementary eye patches– one on a right eye and one on the left. That way the dogs would be mirror images of each other. I created this bull terrier puppy and parent sculpture using four different colored clay bodies, finished with stain and washes and fired to cone 5. It stands about 11 inches tall.


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East Village still recovering after blast
JASON SHALTIEL
Several buildings in the area are still without gas.
The site of the explosion in the East Village, which took place on March 26, 2015, is pictured on Thursday, Feb. 11, 2016. Photo Credit: AFP / Getty Images / Timothy A. Clary
The East Village blast devastated the community, killing two men, injuring 13 others and leveling three buildings.
The neighborhood unified behind the recovery, however, raising over $50,000 last year to reopen B&H Dairy, which had been closed for five months because the collapse had left the business without gas, while local businesses began a renewed push to support one another through membership in the East Village Independent Merchant Association (EVIMA).
"There definitely was a really powerful and moving response on the part of the community," said Andrew Berman, the executive director of the Greenwich Village Society for Historical Preservation.
B&H owner Fawzy Abdelwahed deeply appreciated the grassroots support that sustained a neighborhood institution since the 1930s. "All our customers supported and helped us reopen," he said.
"Things are getting back to normal," he added.
But several buildings in the area are still without gas, according to Abdelwahed.
Lindsey Piscitell, the director of programming at EVIMA, and a 12-year resident of the East Village, said that the building collapse also made local residents more cautious of their landlords.
"I live in a building that is also owned by Maria Hrynenko (the building owner charged on Thursday) and my neighbors and I have been much more communicative in terms of … sharing information," Piscitell said, " People have become more diligent because they've seen what happened if they do not," she added.
After the blast many of small businesses joined The East Village Independent Merchants Association, which promotes over 60 small and independent businesses in the East Village.
"Once (the blast) happened, the merchants felt even further the vulnerability over their tenancy here," said Carol Crump of the East Village Community Coalition. "(EVIMA) is trying as hard as they can to protect them and proliferate those types of shops."
While there are no plans to develop the vacant lot where the collapse occurred, the community will have a say in what will go there, as the site is a historic landmark.
"Some people wish it were a park or a community garden; I would like to see it become an art project," said Jimmy Carbone, East Village resident and owner of local staple Jimmy's No. 43. "There's a big gaping hole here and it's been hard on the community."
Bernie Sanders campaign releases ad featuring Eric Garner's daughter
Teen boy fatally shot on Miller Avenue in East New York, NYPD says

redpajama_set_name: RedPajamaCommonCrawl


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Federal Reserve poised to raise rates a half-per cent
May 3, 2022 by admin 0 Comments
This is an audio transcript of the FT News Briefing podcast episode: Federal Reserve poised to raise rates a half-per cent
Jess Smith
Good morning from the Financial Times. Today is Tuesday, May 3rd. And this is your FT News Briefing.
US central bankers are meeting today amid expectations for a half point interest rate hike. Amazon workers voted no to the latest attempt to unionise a warehouse.
Taylor Nicole Rogers
This is a major, major setback.
Plus, demand for wind energy is soaring, but that's not translating into big profits. I'm Jess Smith, in for Marc Filippino, and here's the news you need to start your day.
Amazon warehouse workers in New York City have rejected an effort to form a union. It's a very different outcome the last month, when organisers succeeded in unionising a warehouse just across the street. I asked the FT's Taylor Nicole Rogers why one facility voted yes and the other no.
Well, I think a lot of labour leaders are going to spend the rest of the year trying to figure that out. But if I had to make one guess logistically, it's that the leaders of this Amazon Labor Union were actually all employees at the facility across the street. The one where they won last month. So just logistically, it would be harder for them to make inroads at this facility, get to know people, engage workers, those kinds of things, especially in the face of really fierce opposition from Amazon.
So Taylor, we've got these two cases in New York with split results, and we still don't have a result from another Amazon union battle from last year. That's the one in Bessemer, Alabama. Amazon's still challenging those results. But does this say anything about the broader effort to unionise at Amazon?
I think it just shows how difficult it is. I think a lot of people last month were saying, oh, we're at this huge moment when a new labour market, everything is going to be so much better for workers. But I think this just goes to show how logistically difficult it is to pull off a victory like the one they saw last month. And just from my conversations with these workers, I know that they are very, very determined and they will certainly be filing for another election as soon as they're allowed to. So I wouldn't say that this is, you know, a once and for all loss for them. But it, of course, is a major, major setback.
That's the FT's US labour and equality correspondent, Taylor Nicole Rogers.
Also in the US, yields on the 10-year Treasury popped up to 3 per cent yesterday as investors braced for the Federal Reserve to raise rates. Fed officials begin a two-day meeting today, and the expectation is that they'll raise rates by half a percentage point. Here's the FT's Colby Smith.
Colby Smith
So this half point increase would be the first time since May of 2000 that the Fed is taking this kind of aggressive action. And I think it really just shows that the Fed has quite a lot of catching up to do when it comes to bringing policy to a more appropriate stance in light of both the strength of the labour market and tightness there, as well as the overshoot of inflation beyond its 2 per cent target.
Colby, I wanna ask you more about that, this idea that the Fed is playing catch-up. You spoke to a former Fed governor who said the Fed wishes it had started earlier. Obviously, hindsight is 20/20, but is that a popular opinion that the Fed should have started tightening earlier?
I think when you see the scope of inflation today, in a lot of ways, people hope that the Fed, you know, had started to scale back some of that accommodation earlier. But of course, some of the shocks that have exacerbated the inflation situation were really impossible to forecast. It would have been quite difficult to have, let's say, predicted that we would have seen this kind of full-scale invasion of Ukraine by Russia, which has really helped to kind of push food and energy prices higher, which in turn has pushed up headline inflation. But even before we got that shock, some of the kind of pandemic bottlenecks, supply chain issues, you know, really strong demand for goods, all of that had combined to create the inflation situation that has persisted for quite some time. So I think in a lot of ways a lot of these things were quite difficult for the Fed to have forecasted. But I think there has been a wholesale criticism that they perhaps were a bit too slow to remove that policy support.
Colby, the Fed has been very clear in telegraphing this half-point rate rise. Are markets ready for this or do you think there could be a reaction?
So markets are definitely prepared for this. Something that Jay Powell, the chair, has done over the past couple of months is be very explicit in the lead up to these meetings about what exactly the Fed is going to do and the way in which Powell kind of talked about it also alluded to the fact that we could see multiple of these 50-basis point hikes this year as the Fed seeks to push its benchmark policy rate to a more neutral setting that no longer stimulates growth and encourages demand. So markets have priced in, you know, looking beyond May, two more 50 basis point hikes this year, as well as further action for the remainder of the year. So in a lot of ways, markets are wholly prepared for this aggressive move.
Colby Smith is the FT's US economics editor.
European countries are planning to use more renewable energy to reduce their dependence on Russian oil and gas. But an earnings report out yesterday from the world's largest wind turbine maker is a reminder that more demand doesn't necessarily mean lots of profit. The Danish company Vestas reported a bigger than expected loss in the first quarter and it slashed its outlook for the rest of the year. Here's the FT's Richard Milne.
Richard Milne
Just really like the whole renewable energy industry, it's been on something of a rollercoaster ride recently. Got a lot of wind in its turbine, so to speak, by Russia's invasion of Ukraine. But the problem it and the rest of the industry has is they're having real trouble making money. They've got a lot of cost inflation with things like steel, but also transporting parts around the world. So it's sort of quite an odd picture.
Richard, are these issues just affecting wind energy or are you seeing this with other kinds of renewables?
Yeah, well, so this is one of the big questions, because what we've seen in the sort of solar panel sector that essentially any US or European attempts to compete in the industry just got completely crushed by Chinese companies. And there are some people who are sort of similarly apocalyptic about wind power. Now, a lot of these companies been around, they've got a very strong track record. Vestas, Siemens Gamesa, you know, they do very well in offshore wind, which is primarily something that's taken place in Europe. So they've got some things to hope for. But at the same time, governments aren't exactly looking to push the price of power up. So these companies have got to find a way of making money without government subsidies and to deal with this sort of cost inflation they've got at the moment.
So how important is wind energy for countries as they try to transition to greener alternatives?
I think it's absolutely central to it. It's hard to see a sort of green transition without wind energy of some sort. In some countries, this could provide bulk of energy to come with some kind of baseload from gas or nuclear or some hydropower or something like that. But I think for many countries and in the west, wind power is the future. And in order for that to work, you need companies like Vestas can make decent returns. So it's gonna be critical to see how this works out.
Richard Milne is the FT's Nordic and Baltic bureau chief.
Efforts to make the shipping industry a bit greener got a big boost yesterday. One of the world's biggest shipping nations, Japan, told an industry regulator that it would support a carbon tax. Japan put forward a proposal that would have industry pay for every tonne of CO2 that it emits. The plan initially would raise more than $50bn a year. The funds would be channelled back into projects aimed at reducing emissions from shipping.
Before we go, a quick correction. Yesterday in our story about Italy's relations with Russia, we said that Silvio Berlusconi was prime minister when he travelled to Crimea to meet with Putin in 2014. In fact, he'd already stepped down.
You can read more on all of these stories at FT.com. This has been your daily FT News Briefing. Make sure you check back tomorrow for the latest business news.
This transcript has been automatically generated. If by any chance there is an error please send the details for a correction to: typo@ft.com. We will do our best to make the amendment as soon as possible.
Trading Breakouts Strategy
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As is well known trees get nourished by eating motorcycles. The loops are essential for such process. See here.
Is that a two-mass-hard box, or a three-mass triangle?
It seems that photo has been under the knife of Adobe Photoshop or similar. Can you spot the blurred parts of the photo, just above the loop?
It's completely undoctored. All I did was down-sample it from the original 3264×2448 to 800×600. I didn't even crop it, or adjust the brightness/contrast.
If you see any artifacts, blame the JPEG compression.


Mastering the art of self-marketing takes practice and a commitment to improvement.
For years I worked diligently at my desk, approving check runs, producing financial statements, and silently praying nobody would knock on my office door. Born an only child, I have thrived solo all my life. I spent years in a company where I sat at the boardroom table, but my ideas were never implemented. Why? I had earned myself a management role, but I was too intimidated and uncomfortable with the thought of stepping outside my comfort zone to vocalize my thoughts and ideas. I was my own worst enemy. I told myself "no" before anyone else had the opportunity to do so.
One day a consultant visiting the company told me something nobody else ever had. She said, "Anne, you need to learn how to market yourself. If you don't effectively toot your own horn, who will?" Market myself? I broke out in a cold sweat at the mere thought of it.
As with any other skill, marketing myself took practice—lots of it. I'm still no extrovert, but I've come to realize that I can succeed as an introvert, too. Through the years, I learned to embrace the characteristics I had as a more reserved person, constantly absorbing information around me. I began pushing myself out of my comfort zone to practice the skills that didn't come so naturally. I've also had the benefit of meeting many CFOs and vice presidents of finance who, as introverts, had learned how to excel in an extroverted business culture.
I tend to be more reserved, and people with that quality are often great listeners. We feel no need to compete for the mic at every meeting. On conference calls, we listen, process, and analyze. So how do we get heard? We rarely make impetuous or impulsive decisions. So how does an intelligent yet gentle-natured CFO gain respect? Market herself?
Be prepared. Introverts generally prefer to listen and don't tend to be impulsive or jostle for position at a meeting, but we can use good preparation to help create the confidence we need to share thoughts and ideas in a way that will make others listen. By understanding the meeting agenda or the topic of the upcoming conference call, we can do the research and analysis in advance. We can make note of the information we want to add to the conversation. A reserved person often is more comfortable speaking up and participating when he or she thoroughly understands the subject matter.
Embrace your skills. You may not be one to walk into a room and "work the crowd." Should you simply forgo networking? Skip the company mixer? Absolutely not! Chances are you excel at relationship building in a one-on-one setting. Again, some advance planning may help. Gain knowledge of potential attendees at the event. Surely there will be two or three people you would like to meet. If you know someone else who's attending the event, ask them in advance if they could make the introduction. (Yes, you can request the introduction by email.) Do your homework so that you feel prepared to discuss a topic of joint interest once you're introduced at the event. LinkedIn can often be a tremendous tool for such background information. Does the person have any experience or education in common with you? Do you share an interest in the nonprofit sector? Perhaps the colleague worked in an industry of significance to you. The possibilities are endless. Remember: You're a good listener, so asking the person a few open-ended questions could easily spark a conversation that flows naturally. If you're prepared, you'll find it easier to feel in control of the conversation and to strengthen your network.
Reenergize. Let's face it. If you aren't an extrovert, it can be draining to be in demanding social situations, leaving you feeling exhausted. I have listened to numerous TEDx speakers and other professionals who are adamant that it's critical to take the much-needed time to reenergize yourself. It doesn't have to be hours at the spa (although if you can make that work, more power to you), but taking a walk around the block or reading a book could be just what you need to refresh yourself. You're a highly valued asset to your organization. Don't overlook the importance of allowing yourself this luxury.
Practice makes perfect. I've been a fan of the Olympics for many years. Although not an athlete myself, I can certainly appreciate the dedication each competitor has to the sport. I remind myself that these athletes didn't just wake up one morning able to jump seven feet, clear an obstacle, or flip and land on a narrow beam with grace. It took practice. Marketing yourself and networking are no different. It takes determination and a willingness to fail and do it again. I can vividly remember walking into a networking event with the goal of meeting a couple new people. Once I walked through the door, I saw 100 unfamiliar people all talking in tight little groups. I broke out in a sweat, went to the restroom, and then left the event. But I didn't permanently hibernate in my office. I took a deep breath and went to another event. Eventually I became more comfortable and could approach a group and politely get myself involved in the conversation.
Anne Leighty is managing partner of the West Michigan ProNexus, LLC, and a member of IMA's Global Board of Directors. You can reach her at aleighty@pronexusllc.com.
At a recent conference, this same topic was discussed at length. The one idea I garnered from the speech (by a very successful freelance writer and introvert) was that as introverts, when we have a purpose at a networking event for example, we are much more comfortable. at the conference, this writer had a purpose: to give a speech and therefore she was comfortable in the situation.
Quite inspiring story from a practitioner with enviable results. Thanks for sharing.


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Catherine Crisp, PhD, MSW, MSC Teacher
Social work professor, social justice educator, feminist, grateful meditator, and mindful self-compassion teacher.
Mindful Self-Compassion
MSC Fall 2019 class
MSC Spring 2019
MSC Workshops and Presentations
Community of Hope Retreat: November 1 – 2, 2019
Intro to Mindful Self-Compassion on March 9, 2019
NASW-AR 2019 Annual Conference Presentation
MSC Survey
GAP Scale
Faculty appointment:
MSW Coordinator and Associate Professor with Tenure at the University of Arkansas at Little Rock
Self-compassion and prejudice: An exploratory study
Use of mindfulness and self-compassion in addressing privilege and prejudicial attitudes.
Self-Perceptions of Gender Affirming Care by Speech-Language Pathology Graduate Students
after Transgender Clinical Experience (with Greg Robinson)
Crisp, C. (2014). White and lesbian: Intersections of privilege and oppression. Journal of Lesbian Studies, 18 (2), 106-117.
McKinzie, K. & Crisp, C. (2013). Employers' use of social media for background checks. Business Research Yearbook. International Academy of Business Disciplines, 23 (2).
Crisp, C. (2012). Correlates of homophobia and gay affirmative practice in rural practitioners. Journal of Rural and Community Psychology, 15 (1). Available at http://www.marshall.edu/JRCP/V15%20N1/15.1%20Crisp%20Ready.pdf
Crisp, C. & DiNitto, D. M. (2012). Addressing substance abuse among gay, lesbian, bisexual, and transgender people. In D. M. DiNitto & C. A. McNeece (Eds.), Social work: Issues and opportunities in a challenging profession (4th ed.), (pp. 336—353). Boston, MA: Pearson.
Padilla, Y.C., Crisp, C., & Rew, D. L. (2010). Parental Acceptance and Illegal Drug Use among Gay, Lesbian, and Bisexual Adolescents: Results from a National Survey. Social Work, 55 (3), 266-275.
Koenig, T. L. & Crisp, C. (2008). Ethical issues in practice with older women who misuse substances. Substance Use & Misuse, 43 (8), 1045 – 1061.
Crisp, C., Wayland, S., & Gordon. T. (2008). Older gay, lesbian, and bisexual adults: Tools for age-competent and gay affirmative practice. Journal of Gay and Lesbian Social Services, 20 (1/2), 5 – 29.
Bailey, G., Onken, S., Crisp, C., & Sloan, L. (2007). Social work practice with gay, lesbian, bisexual, and transgender people. In D. M. DiNitto & C. A. McNeece (Eds.), Social work: Issues and opportunities in a challenging profession (3rd ed.), (pp. 121—143). Chicago, IL: Lyceum Books.
Crisp, C. & McCave, E. L. (2007). Gay affirmative practice: A model for social work practice with gay, lesbian, and bisexual youth. Child and Adolescent Social Work Journal, 24 (4) 403–421.
Crisp, C. (2007). Gay affirmative practice: Knowledge, attitudes, and skills for social work practice with gay and lesbian clients (online teaching module). Washington, DC: Association of Baccalaureate Social Work Program Directors. Available http://www.bpdonline.org/site/indexer/178/content.htm
Crisp, C. (2006). Correlates of homophobia and use of gay affirmative practice among social workers. Journal of Human Behavior in the Social Environment, 14 (4), 119 – 143.
Crisp, C. (2006). The Gay Affirmative Practice Scale (GAP): A new measure for assessing cultural competency with gay and lesbian clients. Social Work, 51 (2), 115 – 126.
Crisp, C. (2005). Homophobia and use of gay affirmative practice in a sample of social workers and psychologists. Journal of Gay and Lesbian Social Services, 18 (1), 51 – 70.
Van Den Bergh, N. & Crisp, C. (2004). Defining culturally competent practice with sexual minorities: Implications for social work education and practice. Journal of Social Work Education, 40 (2), 221 – 238.
DiNitto, D. M., & Crisp, C. (2004). Alcohol use disorders and disabilities module. In Social work education for the prevention and treatment of alcohol use disorders. Washington, DC: National Institute on Alcohol Abuse and Alcoholism. Available at http://pubs.niaaa.nih.gov/publications/Social/ContentsList.html
Crisp, C. (Spring 2004). Gay affirmative practice: A model of treatment with substance abusing gay, lesbian, bisexual, and transgendered clients. Issues of Substance (The newsletter of the NASW ATOD Section), 9 (1), 1, 10 – 11.
Crisp, C. & DiNitto, D. M. (2004). Substance abuse treatment with sexual minorities. In C. A. McNeece & D. M. DiNitto, Chemical dependency: A systems approach (3rd ed.), (pp. 401 – 422). Boston: Allyn and Bacon.
Padilla, Y. C. and Crisp, C. (2003). Gays and lesbians in American society: Policy and practice issues. In T. B. Bent-Goodley and K. E. Davis (Eds.), Teaching social policy: Model course outlines and modules (pp. 135 – 143). Washington, DC: Council on Social Work Education.
DiNitto, D. M., & Crisp, C. (2002). Addiction and women with major psychiatric disorders. In L. A. Straussner & S. Brown (Eds.), The handbook of addiction treatment for women: Theory and practice (pp. 423 – 450). San Francisco: Jossey Bass.
Crisp, C. (2002). Selected characteristics of research on lesbian women: 1995-1997. Journal of Homosexuality, 44(1), 139 – 155.
Crisp, C. (1996) . Dual diagnosis: Substance abuse and mental health in an inpatient setting. In L. Grobman (Ed.), Days in the lives of social workers (pp. 121 – 126). Harrisburg, PA: White Hat Communications.
Recent Awards:
College of Education and Health Professions Dean's Award: April 2017
National Association of Social Workers Arkansas Chapter Lifetime Achievement Award: March 2017
University of Arkansas at Little Rock Students Affected by the Military Service to Veterans Award: November 2015
UA Little Rock GRAD Advising Award: April 2013, 2015, 2018
UA Little Rock Adult Student Advocacy Program Faculty Mentor Award: Spring 2011
National Association of Social Workers Arkansas Chapter Presidential Award for Outstanding Service: April 2010


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Wood Ducks Win In Extras Against Fayetteville
Matthews strikes out career-high 12
By Matt Davis
Kinston, N.C. – The Down East Wood Ducks tallied their sixth walkoff win of the season with a 5-4 win in 11 innings against the Fayetteville Woodpeckers, Wednesday night. John Matthews had a career day as he set a career-high with 12 strikeouts. For the second game in-a-row, Fayetteville (44-54)
Kinston, N.C. – The Down East Wood Ducks tallied their sixth walkoff win of the season with a 5-4 win in 11 innings against the Fayetteville Woodpeckers, Wednesday night. *John Matthews *had a career day as he set a career-high with 12 strikeouts.
For the second game in-a-row, Fayetteville (44-54) opened the scoring with a run in the second and two in the third to take a 3-0 lead.
Down East (58-40) started to climb back with a run in the bottom of the fourth. Luisangel Acuña led off with a walk and stole second (36). Keyber Rodriguez singled and that scored Acuña to make the score 3-1.
The Wood Ducks plated another run in the bottom of the sixth. With one out, Acuña singled and stole second (37). Rodriguez grounded out but Acuña advanced to third on the play. With *Cody Freeman *at the plate, Acuña scored on a wild pitch to cut the deficit to 3-2.
Down East managed to tie the game down to their final out in the bottom of the ninth. With two outs, Freeman blasted a solo home run (5) to force extra innings.
Fayetteville plated a run in the top of the tenth to take a 4-3 lead.
The Wood Ducks came back to tie the game in the bottom of the tenth. With *Keithron Moss *pinch running at second, *Xavier Valentin *flew out to center but Moss advanced to third. *Cristian Inoa *singled to score Moss and tie the game at four.
After a scoreless top of the 11th, the Wood Ducks plated the winning run in the bottom of the inning. Jayce Easley *started the inning at second and advanced to third on a passed ball. *Daniel Mateo hit a single to score Easley and give the Woodies the 5-4 win.
Matthews took the no-decision but had a great outing as he pitched 5 1/3 innings with three runs allowed on six hits with two walks and a career-high 12 strikeouts. Eris Filpo pitched 4 2/3 innings with one unearned run allowed on six hits with four strikeouts. *Eudrys Mañon *(2-0) earned the win as he pitched one scoreless inning with two strikeouts.
The series continues tomorrow with first pitch set for 7:00 p.m. RHP Nick Lockhart (1-0, 9.89) gets the ball for Down East and Fayetteville will counter with RHP Elian Rodriguez (1-2, 3.68).
Fans can purchase tickets on woodducksbaseball.com, by calling the Wood Ducks Team Offices at (252) 686-5164 or in the Wood Ducks Team Offices located at Grainger Stadium (Mon-Fri – 9am - 4pm). Make sure to follow your Down East Wood Ducks on Instagram, Twitter, and Facebook so you don't miss anything!
Cody Freeman
Jayce Easley
Cristian Inoa
Keyber Rodriguez
Eudrys Manon
Eris Filpo


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When reviewing Larry Murante's marvelous Point of Entry (here), I mentioned Robyn Landis' collaboration with him on a couple of songs. Well, he's here as well, singing and playing guitar, and I can, after hearing Many Moons, very easily see why he chose her to work with...and vice versa.
Landis sings with a high, clear, laconically sweet voice informing the listener of the bittersweet nature of her work well before the lyrics are digested and pondered. I'm constantly reminded of a high plains vibe when listening to her material, all of it uncomplicated but beautifully melodic, the kind of easy tempos and sonorities one can fall readily into, happy to lay back and gently reminisce on the universality of living the human life.
Landis' guitar work is as gauzily soporific as her singing, spiced with great harmonica interludes by Mark Graham, here not as a blues instrument but instead harkening back to the days of Twain and his white picket fences, dirt roads, and rural sentiments. Likewise, Cary Black is the constant bassist, and he oscillates between pointillistic expression and gentle rhythmic undercurrents, often supplying the entire rhythm section (only 3 cuts carry percussion) and a large part of the deceptively wide baseline. Half the tracks further incorporate Jami Sieber's cello work in lazy skyblown complements to Landis' earthier presence.
Every cut here is a keeper, and Landis obviously either lavished a good deal of time on the arrangements or has a natural gift for it, probably both. Like David Wilcox, her work is rich with sympathy for human frailty and the thousand and one disappointments the flesh is heir to. Guitars and voices dominate the release but not roughly at all. In fact, the layering is so quietly hypnotic that you hardly notice anything but the tapestry of laving tones drifting whisperingly in the ear. Even given the longing and mysteries pervading every minute of the dozen cuts (housed in gorgeous tri-fold packaging with full credits, notes, and lyric booklet), this is a very refreshing CD and stays so each time it's broached. Hard to believe it's her debut solo release, but that's indeed the case—of course, the fact that she has a list of awards and recognitions as long as your arm explains a lot of that. Robyn Landis, I'm quite sure, waited until her art was fully matured and, man, does it ever show.
Folk & Acoustic Music Exchange
Mark S. Tucker
Copyright 2009, Peterborough Folk Music Society.
This review may be reprinted with prior permission and attribution.
Mark S. Tucker - Folk and Acoustic Music Exchange (Jul 31, 2009)
Picture this: the wind blows a whirling dust devil across the broad open plain as the young woman stands outside of the rustic cabin and gazes with weary, strained eyes far into the empty distance. The first spare verse of Jamison Brown, co-written with David Zink, paints a clearly defined opening scene in just ten carefully selected words. This is an admirable skill for a song writer to possess and Robyn Landis seems to do it so well through out her new CD titled Many Moons, whether it be in her co-writing or solo compositions. Ms. Landis' smooth vocals caress the sensitive poetry and bittersweet sorrow...The studio work of every musician featured is exquisite...she nails it beautifully with her tender sweet voice. If it's possible to write at the cellular level, Robyn Landis does just that... With each literary illustration, the landscape blurs by around another winding curve and bump in the road; another set of headlights grow then disappear in a flash, and yet a ghostly image remains. Ah yes, she can put you behind the wheel with her cohesive words and melody...Landis has been turning heads at many songwriters' contests and festivals and as a result has chocked up her share of nominations and awards. Listening to the content and production quality of Many Moons, there is no doubt as to why. Landis has a way of articulating so many of life's experiences along with a certain sense of community from a poet's perspective...Many Moons is a brightly polished piece of work that will capture and carry you gently along on an intricate narrative adventure; an exceptional release.
- Nancy Vivolo for Victory Review
Nancy Vivolo - Victory Music Review (Aug 5, 2009)
"While Trees Fall is Landis' political ecological statement that comes off ten times better than some of the current attempts...subtle and indicting lyrics."
JAKE NUCKOLLS, Editor - CDREVIEWS.com
...smooth vocals, like an earthy Laurie Lewis...right-on bass from the fabulous Cary Black, lively fiddle from Paul Elliot and more...a relax-in-your-chair big ol' dose of straight-ahead folk... Landis has won a lot of songwriting awards, and it's easy to see why. She's great at taking a moment in time and using it to convey an emotion so strong that everyone listening will nod their heads, remembering a time in their own lives when they felt the same. Her promo material says she's been compared to Dar Williams, but I don't see that in her writing. Dar's writing is more philosophical, and while there's a hint of that in Robyn's work, her writing is more descriptive, like a good short story... "Winter Blues" opens the disc, a leaping fiddle leading the way, the upbeat arrangement a contrast to the melancholy lyrics... There's an ache in Robyn's voice in "Say Goodbye" that would tell you the story even if you weren't listening closely to the words (but you should). An acoustic guitar, simple bass, violin and vocals wrap lovingly around the melody. Beautiful...The standout cut is "While Trees Fall," a statement about our planet and what we're doing to it. She implores: They want to get into heaven through the eye of a needle Let me in before the ones in suits can even try Can I be an angel so I can ask some questions before I let 'em by ... Amen, sister, amen.
Jamie Anderson - INDIE-MUSIC.com (Dec 2, 2007)
"The opening line of While Trees Fall hits you over the head and sends your brain swirling and waiting on the next lyric. It gives you chills...It's a philosophical attack on corporate America and its use of media manipulation, lies, and pursuit of financial gain at all costs...transports you back to the time when folk songs and the stories that fueled them were the mainstream norm and kept droves of people packed in coffeehouses in complete silence listening to every word in the story, so as to not miss any profound insights or endearing thoughts."
JULIAN SKYE - AlphaMusicGroup
"While Trees Fall is very straightforward and takes a shot at leaders who are aiming for heaven, but might not get there if this songwriter beats them there first. Robyn Landis is able to inject a little humor to a very serious subject: 'They never take my calls / They haven't got the balls / They just have lies is all / while trees fall and fall and fall.' Finally, a song that says what it means, performed by a singer who appears to mean what she says."
- Peacedriven Songwriting Competition
"For those of us who've been already been enjoying Short and Sweet at festivals and concerts, here's what we've been waiting for: a beautiful collection of their original songs. The studio work is excellent, and at the same time, it sounds just like their live performances: their shiny-smooth vocal blend, emotional impact, and really cool instrumental arrangements. The songs cover a big range of feeling, from the inward and personal to the intense and outspoken political. Some songs are quite contemporary, and a few--like "Calico Creek"--sound like they could've been written one hundred years ago. What a treat it is to finally have them on CD."
songwriter, producer, composer, guitarist, and music professor (Cornish College of the Arts) acclaimed recording artist - Linda Waterfall
Robyn Landis is a terrific singer and songwriter, and all around responsible and decent person. Just give her music a listen and you will see what I mean. Head, heart and guts all wrapped up in a beautiful voice and guitar.
Gene Burnett (Jul 9, 2011)
I first heard Robyn Landis at our Tucson Folk Festival, where she's been invited to play for the past 7 years. After the first year, I made it a point to catch her set each year after. After the third time I heard her I was completely won over by her musicianship and intelligent lyric writing.
So we exchanged CDs that year. And I immediately fell in love with her latest release Many Moons, especially her song Leave You Behind. Not only did Robyn write (or co-write) all the songs, she also co-produced the CD and was responsible for art work and design as well. It was a beautiful and impressive piece of work overall.
When Robyn first moved to Tucson, I invited her to share a house concert with my Band BK Special, and joined her on several of her songs including Leave You Behind.
I've been a musician all my life, and I've achieved some success. I toured and recorded with Linda Ronstadt as a member of The Stone Poneys, and also toured with folk music legend Doc Watson. I ran one of the premier acoustic music venues in the country, McCabe's Guitar Shop in Santa Monica, for 7 years. I booked acts like Jackson Browne, Bonnie Raitt, Emmylou Harris, Tom Waits, Chet Atkins and the rock band Little Feat. So I feel confident in my ability to evaluate musical talent.
I think Robyn is one of the most intelligent songwriters on the scene today, a thoroughly professional musician, and I remain her committed fan.
Bobby Kimmel
Bobby Kimmel (Aug 16, 2011)
August, 2012 - "I have been lucky to choose great artists–-all hits no misses. Robyn Landis was proof of my good fortune. Once again 28 folks went home smiling and thanking me for inviting them and hosting another wonderful artist. Robyn is the real thing, honest, incredibly smart, a voice that gives me goose bumps and tears all together, and she's drop dead beautiful. Let's do it again, Robyn."
(J. Borger--Concerts on the Lake, Allyn, WA)
John Borger - Concerts In Your Home (Aug 5, 2012)


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redpajama_set_name: RedPajamaGithub


President Obama is proposing free community college. We are finally investing in our most important assets.
In our growing global economy, Americans need to have more knowledge and more skills to compete — by 2020, an estimated 35 percent of job openings will require at least a bachelor's degree, and 30 percent will require some college or an associate's degree. Students should be able to get the knowledge and the skills they need without taking on decades' worth of student debt. If you're starting college soon, take a look at this custom thesis writing service to see how it can help you.


An Embroidery Encore brings a brilliant harvest of delicious fruit wreaths! Bright fruit is ripe and ready to add fresh color and style to your embroidery projects.
Blueberries, watermelon, oranges, cherries, peaches, raspberries, and other fruit combine with blossoms and leaves into elegant circle bouquets, bringing nature's beauty to summer stitching.
Create a splendid look for summer with tasty fruit wreaths on placemats and linens!
Blueberries and apples are some of the healthiest foods on earth, and make smart embroidery embellishments, too. Circles of fruit add a colorful look to aprons, towels, trivets, and more.
7.79" x 7.80" and 6.90" x 6.91" and 5.86" x 5.87" and 4.84" x 4.85" and 3.86" x 3.86"
Cool off your embroidery projects with sweet-tasting strawberries and mouth-watering watermelon -- both at their peak of flavor during the hot summer months.
7.80" x 7.78" and 6.93" x 6.90" and 5.88" x 5.86" and 4.86" x 4.85" and 3.85" x 3.84"
Stitch your recommended daily allowance of vitamin C and potassium with oranges and bananas, tasteful and healthy additions to kitchen and dining room linens.
7.76" x 7.80" and 6.90" x 6.94" and 5.86" x 5.89" and 4.84" x 4.87" and 3.84" x 3.86"
Cranberries aren't just for Thanksgiving and Christmas! Brilliant berries add gorgeous color to towels, tote bags, and more. And, a wreath of lemons is vibrant with sunshine yellow fruit and delicate blossoms. Add to reusable grocery bags for a very fresh look.
7.79" x 7.80" and 6.90" x 6.91" and 5.86" x 5.86" and 4.84" x 4.85" and 3.85" x 3.85"
Mangoes are miniature tropical sunsets in a fruit, while limes add fresh flavor to salsa and margaritas. Stitch onto pillow shams for a refreshing and tasty addition to any room.
7.80" x 7.74" and 6.95" x 6.90" and 5.90" x 5.85" and 4.87" x 4.83" and 3.86" x 3.83"
Create a gorgeous fruit cocktail with ripe and juicy cantaloupes and fresh cherries. Both are linked to an ever-increasing array of health benefits. They're good-looking and good for you!
7.78" x 7.80" and 6.90" x 6.93" and 5.85" x 5.88" and 4.83" x 4.85" and 3.84" x 3.86"
Perfectly ripe plums are pleasing in shades of purple, while pears add cool and crisp appeal to aprons, towels, placemats, table toppers, tote bags, and more.
7.80" x 7.80" and 6.90" x 6.90" and 5.86" x 5.86" and 4.86" x 4.86" and 3.87" x 3.87"
The fruits of summer are here for only a short time, so enjoy them now! Everything is just peachy with the wreath on the left, and on the right apricots glow with warm seasonal color.
7.78" x 7.78" and 6.89" x 6.89" and 5.86" x 5.86" and 4.86" x 4.86" and 3.86" x 3.86"
Raspberries are naturally inclined to grow in cooler climates, making them a perennial favorite of northern gardeners. Juicy grapes come in all colors -- match colors to your project needs.
7.80" x 7.78" and 6.92" x 6.90" and 5.90" x 5.88" and 4.88" x 4.86" and 3.88" x 3.87"
If you're not already a fan of figs, you will be when you see how lovely they are in their natural state, with a deep purple exterior revealing a pearly pink fruit. So pretty! And, add a tropical touch to summertime stitching with a papaya -- the "fruit of the angels."
7.78" x 7.80" and 6.90" x 6.92" and 5.86" x 5.88" and 4.85" x 4.86" and 3.84" x 3.87"
Fresh summer stitching is in the bag with the Fresh Fruit Wreath Design Packs. Get all the beautiful and nutritious fruit for healthy quilts, pillow covers, wall hangings, towels, and more!
Order the designs individually by clicking the links above, or get the pack with all 20 designs. Five sizes are available to suit any project.
Drawing and digitizing embroidery designs ignites our creative spirit. We dreamed up a couple of ways to use these fruit wreaths, and wanted to share our ideas with you!
The graceful wreath shape is a perfect fit to the bodice of an apron. We used one piece of cutaway stabilizer (2.5 ounce) on the back.
Bring the rainbow colors of fresh fruit to your summer projects!
Colorful wreaths are beautiful on placemats! We hooped a piece of cutaway stabilizer, then affixed this straw placemat to the stabilizer with spray adhesive and pins. A sharp needle (size 11) is perfect for penetrating the weave of the "fabric."


Broken Kettle Grasslands is the Nature Conservancy's largest preserve in Iowa with 4,500 acres of natural beauty showing loess topography and native prairie. The terrain is steep and rugged in some areas and predominantly grasslands. The extensive prairie ridgetops feature a variety of rare plants and animals. See breathtaking vistas while you hike. The preserve contains some flora and fauna not found in any other part of the Loess Hills to the south or the state of Iowa; these include the prairie rattlesnake and the 10-petal blazing star.
overlooks of Nebraska, South Dakota, and Iowa.
who began to develop the area for a park nearly 100 years ago.
when they decided they wanted it back, he would not comply so many of the people decided to move on to Utah. Now Preparation Canyon is a state park offering hiking trails, campsites, and a scenic experience in the Loess Hills.
selecting an item from the shop of Iowa products.


text:
Annual Perspective 13
Interview 138
Perspective 119
Point-Counterpoint 2
Provider-Patient Communication 21
Learning Organization 1
Conferences and Workshops 1
Online Education 1
Patient Education 12
Residents and Fellows 12
Simulators 11
Root Cause Analysis 11
Patient Disclosure 16
Credentialing, Licensure, and Discipline 14
Malpractice Litigation 11
Regulation 15
Logistical Approaches 25
Duty Hour Limitation 10
Computer-Assisted Therapy 1
Computer- or Robotic-Assisted Surgery 1
Transparency and Accountability 3
Missed Care 1
Fatigue and Sleep Deprivation 13
Delirium 3
Psychological and Social Complications 26
Second victims 1
Patient Transport 2
Gynecology 54
Pediatric Radiology 1
Obstetrical Nursing 1
Health Care Executives and Administrators 214
Health Care Providers 163
Non-Health Care Professionals 148
Educators 35
Epidemiology of Errors and Adverse Events 107
Near Miss 1
1 - 100 of 275 results
Emerging Safety Issues in Artificial Intelligence
with commentary by Robert Challen, MA, MBBS, Emerging Safety Issues in Artificial Intelligence, July 2019
This piece explores various practical and philosophical issues that could shape the adoption of machine learning and artificial intelligence systems in medicine.
In Conversation With… Suchi Saria, PhD
Emerging Safety Issues in Artificial Intelligence, July 2019
Dr. Saria is the John C. Malone Assistant Professor of computer science, statistics, and health policy at Johns Hopkins University. Her research focuses on developing next generation diagnostic, surveillance, and treatment planning tools to reduce adverse events and individualize health care for complex diseases. We spoke with her about artificial intelligence in health care.
Building a Safety Program Using Principles of Resilience Engineering
with commentary by Sudeep Hegde, PhD; Ann M. Bisantz, PhD; and Rollin J. Fairbanks, MD, MS, Resilience Engineering and Patient Safety, June 2019
This piece explores the key role of emergency medical services in providing care to patients at their moment of greatest need, safety hazards in this field, and opportunities for improvement.
In Conversation With… Erik Hollnagel, PhD
Resilience Engineering and Patient Safety, June 2019
Dr. Hollnagel is Senior Professor of Patient Safety at the University of Jönköping (Sweden) as well as Visiting Professorial Fellow at Macquarie University in Sydney (Australia). We spoke with him about his work studying safety in health care and the differences between designing safety improvements in health care versus other industries.
Safety in the Prehospital Emergency Medical Services Setting
with commentary by P. Daniel Patterson, PhD, NRP, and Donald M. Yealy, MD, Safety in Emergency Medical Systems, May 2019
In Conversation With… Jane Brice, MD, MPH
Safety in Emergency Medical Systems, May 2019
Dr. Brice is Professor and Chair of the Department of Emergency Medicine at the University of North Carolina. She also serves as the Program Director for the Emergency Medical Services (EMS) Fellowship and was past-president of the National Association of EMS Physicians. We spoke with her about her experience working in emergency medical systems and safety concerns particular to this field.
In Conversation With… … Jennifer Schulz Moore, LLB, MA, PhD
New Insights Into Apology and Disclosure Programs, April 2019
Dr. Schulz Moore is the Director of Learning and Teaching at the University of New South Wales Faculty of Law and an Associate with the University of New South Wales School of Public Health and Community Medicine. Her research in health law draws from her unique training in public health, law, and health social sciences. We spoke with her about disclosure and apology in health care as well as the intersection between health and legal systems in Australia, New Zealand, and the United States.
In Conversation With… Timothy B. McDonald, MD, JD
Dr. McDonald is President of the Center for Open and Honest Communication at the MedStar Institute for Quality and Safety, and Adjunct Professor of Law at Loyola University-Chicago School of Law and the Beazley Institute for Health Law and Policy. An internationally recognized patient safety expert, he served as a lead architect for the Communication and Optimal Resolution (CANDOR) toolkit, supported by AHRQ. We spoke with him about lessons learned over the years regarding event reporting and his insights about building and disseminating communication-and-resolution programs.
Building a Safety Program in a Vast Health Care Network
with commentary by Paul E. Phrampus, MD, Health System Consolidation and Patient Safety, March 2019
This piece outlines how large integrated health care systems can implement effective patient safety programs and spotlights the importance of leadership engagement and a just culture.
In Conversation With… Susan Haas, MD, MSc
Health System Consolidation and Patient Safety, March 2019
Dr. Haas is an obstetrician–gynecologist and co-Principal Investigator for Ariadne Labs' work focused on health care system expansion. We spoke with her about the trend of health systems getting larger and more integrated, the risks to patient safety, and ways to mitigate these risks.
Building Systems Citizenship in Health Professions Education: The Continued Call for Health Systems Science Curricula
with commentary by Jed D. Gonzalo, MD, MSc, and Mamta K. Singh, MD, MSc, Teaching Patient Safety, February 2019
This piece spotlights the need for educational and cultural transformation to achieve sustainable progress in patient outcomes and health.
In Conversation With… Susan E. Skochelak, MD, PhD
Teaching Patient Safety, February 2019
Dr. Skochelak is the Group Vice President for Medical Education at the American Medical Association (AMA). She leads the AMA's Accelerating Change in Medical Education initiative, which aims to align physician training with the changing needs of our health care system. We spoke with her about her experience in medical education.
Maternal Safety
with commentary by Audrey Lyndon, RN, PhD, 2018
This perspective examines the troubling decline in maternal health outcomes in the United States and summarizes recent national initiatives to improve safety in maternity care.
Update: Patient Engagement in Safety
with commentary by Rachel J. Stern, MD, and Urmimala Sarkar, MD, 2018
Patient engagement is widely acknowledged as a cornerstone of patient safety. Research in 2018 demonstrates that patient engagement, when done correctly, can help health care systems identify safety hazards, regain trust after they occur, and codesign sustainable solutions.
The Comprehensivist Model of Care: A Hospitalist's View
with commentary by Robert Wachter, MD, The Comprehensive Care Physician Model, November 2018
This piece, written by the physician who coined the term "hospitalist," provides an overview of the hospitalist model and reflects on key advantages of and challenges faced by the Comprehensive Care Physician Model.
In Conversation With… David Meltzer, MD, PhD
The Comprehensive Care Physician Model, November 2018
Dr. Meltzer is the Fanny L. Pritzker Professor of Medicine, Chief of the Section of Hospital Medicine, and Director of the Center for Health and the Social Sciences at the University of Chicago. His research aims to improve the quality and lower the cost of hospital care. We spoke with him about the Comprehensive Care Physician Model, which he pioneered and was recently featured in an article in The New York Times Magazine.
Safety in the Retail Pharmacy
with commentary by Michelle A. Chui, PharmD, PhD, Safety in the Retail Pharmacy, October 2018
This piece reviews unique characteristics of community pharmacies that can affect medication safety and spotlights the need for further research examining medication errors in community settings.
In Conversation With… Michael Cohen, RPh, MS, ScD (hon)
Safety in the Retail Pharmacy, October 2018
Dr. Cohen is President of the Institute for Safe Medication Practices, a nonprofit organization that operates the voluntary and confidential ISMP Medication Errors Reporting Program. He is also coeditor of the ISMP consumer website, chairperson of the International Medication Safety Network, and a consultant to the Food and Drug Administration. We spoke with him about patient safety in the community pharmacy, including challenges associated with production pressures and the importance of reporting concerns.
In Conversation With… Sigall K. Bell, MD
Patient Engagement, September 2018
Dr. Bell is Director of Patient Safety and Discovery at OpenNotes, Beth Israel Deaconess Medical Center, and Associate Professor of Medicine at Harvard Medical School. Her research focuses on transparency in health care delivery systems and partnering with patients to improve health care. We spoke with her about patient engagement and her experience with the OpenNotes project.
In Conversation With… Rebecca Lawton, PhD
Professor Lawton is Director of the Yorkshire and Humber Patient Safety Translational Research Center, a Professor in the Psychology of Healthcare at the University of Leeds, and a health psychologist who conducts research on human factors and patient involvement in patient safety. We spoke with her about her experience with patient engagement and insights gleaned from her research.
How Does Health Care Simulation Affect Patient Care?
with commentary by Joseph O. Lopreiato, MD, MPH, Update on Simulation, August 2018
This piece explores health care simulation including the four main methods used and the evidence base for its impact on learning and patient care.
In Conversation With… Matthew Weinger, MD
Update on Simulation, August 2018
Dr. Weinger is Director of the Center for Research and Innovation in Systems Safety and Professor of Anesthesiology, Biomedical Informatics, and Medical Education at Vanderbilt University. He holds the Norman Ty Smith Chair in Patient Safety and Medical Simulation. We spoke with him about the current state of simulation training in health care, barriers to progress, and potential innovations.
In Conversation With… Gordon Schiff, MD
Improving Diagnosis, July 2018
Dr. Schiff is Associate Director of Brigham and Women's Center for Patient Safety Research and Practice, Associate Professor of Medicine at Harvard Medical School, and Quality and Safety Director for the Harvard Medical School Center for Primary Care. He was an invited expert and reviewer for the Improving Diagnosis in Health Care report of the National Academy of Medicine. We spoke with him about understanding and preventing diagnostic errors.
In Conversation With… Shantanu Nundy, MD
Dr. Nundy is the Director of the Human Diagnosis Project, a nonprofit organization taking a unique crowdsourcing approach to improving medical diagnosis. He also practices primary care at a federally qualified health center for low-income and uninsured individuals in Washington, DC. We spoke with him about his work with the Human Diagnosis Project.
Safety Considerations in Building a Point-of-Care Ultrasound Program
with commentary by Chris Moore, MD, Point-of-Care Ultrasound: Safety and Utility, June 2018
This piece highlights how point-of-care ultrasound can improve and expedite diagnosis and advocates for having an individual responsible for overseeing point-of-care ultrasound use within a health care delivery organization.
In Conversation With… Richard Hoppmann, MD
Point-of-Care Ultrasound: Safety and Utility, June 2018
Dr. Hoppmann is the Dorothea H. Krebs Endowed Chair of Ultrasound Education, Professor of Medicine, and Director of the Ultrasound Institute of the University of South Carolina School of Medicine. He founded and served as the first President of the Society of Ultrasound in Medical Education. We talked to him about safety and usability of point-of-care ultrasound.
In Conversation With… John Halamka, MD, MS
A Decade After HITECH, May 2018
Dr. Halamka is the International Healthcare Innovation Professor at Harvard Medical School, Chief Information Officer of Beth Israel Deaconess Medical Center, and an emergency physician. He is widely known as one of the most thoughtful and provocative experts on the subject of health IT. We spoke with him about the HITECH Act and the consequences—anticipated and otherwise—of the digitization of health care.
In Conversation With… David Blumenthal, MD, MPP
Dr. Blumenthal is President of the Commonwealth Fund and served as the National Coordinator for Health Information Technology from 2009-2011, during early implementation of the Health Information Technology for Economic and Clinical Health (HITECH) Act and the accompanying Meaningful Use program. We spoke with him about the HITECH Act and lessons learned in health care since it was enacted.
Patient Safety During Hospital Discharge
with commentary by Katherine Liang and Eric Alper, MD, Post-Hospital Syndrome, April 2018
This piece explores the risks patients face after hospital discharge and strategies to address them, such as patient education, Project RED, and the Care Transitions Intervention.
In Conversation With… Harlan Krumholz, MD, SM
Post-Hospital Syndrome, April 2018
Dr. Krumholz is Professor of Medicine at the University of Yale School of Medicine and Director of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation. We spoke with him about readmissions and post-hospital syndrome, a term he coined in an article in the New England Journal of Medicine to describe the risk of adverse health events in recently hospitalized patients.
Missed Nursing Care: A Key Measure for Patient Safety
with commentary by Jane Ball, PhD, and Peter Griffiths, PhD, Nursing and Patient Safety, March 2018
This piece explores how missed nursing care may explain the association between low nurse staffing levels and increased mortality in hospital patients.
In Conversation With… Linda Aiken, PhD, RN
Nursing and Patient Safety, March 2018
Dr. Aiken is Claire M. Fagin Leadership Professor of Nursing, Professor of Sociology, and Director of the Center for Health Outcomes and Policy Research at University of Pennsylvania. She is generally considered the nation's foremost expert on health policy as it relates to the nursing workforce. We spoke with her about how nurse staffing and the work environment can affect patient safety and outcomes.
The Weekend Effect
with commentary by Sumant Ranji, MD, 2017
A considerable body of evidence demonstrates worsened clinical outcomes for patients admitted to the hospital on weekends compared to those admitted on weekdays. This Annual Perspective summarizes innovative studies published in 2017 that helped clarify the magnitude of this effect and identify possible mechanisms by which it occurs.
Patient Engagement in Safety
Patient engagement in safety has evolved from obscurity to maturity over the past two decades. This Annual Perspective highlights emerging approaches to engaging patients and caregivers in safety efforts, including novel technological innovations, and summarizes the existing evidence on the efficacy of such approaches.
EHR Copy and Paste and Patient Safety
with commentary by Shannon M. Dean, MD, Clinical Documentation in the Modern Era, January 2018
This piece explores concerns regarding the use of copy and paste in electronic health records and offers potential strategies to improve clinical documentation accuracy.
In Conversation With… Robert Hirschtick, MD
Clinical Documentation in the Modern Era, January 2018
Dr. Hirschtick is Associate Professor of Medicine at Northwestern Medicine, and the author of a number of prominent articles—many quite amusing—about the changes in medical practice wrought by information technology. We spoke with him about what it means to be a clinician in the modern era, particularly how digitization of health records has affected clinicians' notes.
The Evolution of Patient Safety in Surgery
with commentary by Robert M. Wachter, MD, Surgical Safety, December 2017
This piece explores progress of patient safety in the surgical field and where further improvement can be made, such as ongoing assessment of procedural skills along with video recording and review of surgical procedures.
In Conversation With… Karl Bilimoria, MD, MS
Surgical Safety, December 2017
Dr. Bilimoria is the Director of the Surgical Outcomes and Quality Improvement Center of Northwestern University, which focuses on national, regional, and local quality improvement research and practical initiatives. He is also the Director of the Illinois Surgical Quality Improvement Collaborative and a Faculty Scholar at the American College of Surgeons. In the second part of a two-part interview (the earlier one concerned residency duty hours), we spoke with him about quality and safety in surgery.
The Role of Patient-facing Technologies to Empower Patients and Improve Safety
with commentary by Ronen Rozenblum, MD, MPH, and David Bates, MD, MS, Patient-facing Technologies: Opportunities and Challenges for Patient Safety, November 2017
This piece explores how patient-facing technologies can enable patients to be more responsible for their care and improve the way clinicians practice.
In Conversation With… Wanda Pratt, PhD
Patient-facing Technologies: Opportunities and Challenges for Patient Safety, November 2017
Wanda Pratt is a professor in the Information School and an adjunct in Biomedical and Health Informatics in the School of Medicine at the University of Washington. We spoke with her about patient-facing technologies, including the opportunities and challenges for patient safety.
Health Care Worker Presenteeism: A Challenge for Patient Safety
with commentary by Julia E. Szymczak, PhD, Presenteeism: A Patient Safety Challenge, October 2017
This piece explores the risks of presenteeism among health care workers and factors, such as cultural expectations, that contribute to its occurrence.
In Conversation With… Jeffrey Starke, MD
Presenteeism: A Patient Safety Challenge, October 2017
Dr. Starke is Professor of Pediatrics–Infectious Disease at Baylor College of Medicine and previously served as Infection Control Officer at Texas Children's Hospital. We spoke with him about "presenteeism" (coming to work while ill) in health care and its impact on provider and patient safety.
Assessing the Safety of Electronic Health Records: What Have We Learned?
with commentary by Dean F. Sittig, PhD, and Hardeep Singh, MD, MPH, Health Information Technology and Safety, September 2017
This piece highlights four key lessons that the authors believe are useful for clinicians and health care organizations that seek to identify, prevent, and mitigate electronic health record–related safety issues.
In Conversation With… Andrew Gettinger, MD
Health Information Technology and Safety, September 2017
Dr. Gettinger is the Chief Medical Information Officer and the Executive Director of the Office of Clinical Quality and Safety for the Office of the National Coordinator (ONC). He led the development of an electronic health record (EHR) system at Dartmouth and was the senior physician leader during their transition to a vendor-based EHR. We spoke with him about safety and health information technology.
ACGME's 2017 Revision of Common Program Requirements
with commentary by Kathy Malloy; Timothy P. Brigham, PhD; Thomas J. Nasca, MD, Resident Duty Hours Policy Changes, August 2017
This piece reviews how changes to the ACGME requirements emphasize patient safety and quality improvement, address physician well-being, strengthen expectations around team-based care, and create flexibility for work hours within the maximum 80-hour workweek.
Resident Duty Hours Policy Changes, August 2017
Dr. Bilimoria is the Director of the Surgical Outcomes and Quality Improvement Center of Northwestern University. He is the principal investigator of the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial and a Faculty Scholar at the American College of Surgeons. We spoke with him about the FIRST trial, which examined how less restrictive duty hours affected patient outcomes and resident satisfaction. Its results informed recent changes to duty hour policies.
Doctors With Multiple Malpractice Claims, Disciplinary Actions, and Complaints: What Do We Know?
with commentary by David Studdert, LLB, ScD, Legal Issues and Patient Safety, July 2017
This piece explores the risk of recurring medicolegal events among providers who have received unsolicited patient complaints, faced disciplinary actions by medical boards, or accumulated malpractice claims.
In Conversation With… Michelle Mello, MPhil, JD, PhD
Legal Issues and Patient Safety, July 2017
Michelle Mello is Professor of Law at Stanford Law School and Professor of Health Research and Policy at Stanford University School of Medicine. She conducts empirical research into issues at the intersection of law, ethics, and health policy. We spoke with her about legal issues in patient safety.
The Weekend Effect in Cardiology: Is It Real? If So, Can It Be Fixed?
with commentary by Vanessa K. Martin, DO, MS; Nasim Mirnateghi, PhD; and Mahdi Khoshchehreh, MD, MS, The Weekend Effect, June 2017
This piece explores the weekend effect in cardiology and recommends allowing invasive management for patients with non ST-elevation myocardial infarction to improve outcomes in this group.
In Conversation With… Paul Aylin, MBChB
The Weekend Effect, June 2017
Professor Aylin is Professor of Epidemiology and Public Health at Imperial College London. We spoke with him about the weekend effect in health care—the observation that patients admitted to the hospital over the weekend often have worse outcomes than those admitted during the week.
Opioid Overdose as a Patient Safety Problem
with commentary by Irene Berita Murimi, PhD, MA, and G. Caleb Alexander, MD, MS, Opioids and Patient Safety, May 2017
This piece explores the opioid epidemic in the United States, including factors that led to increased opioid prescribing, its adverse effects, and tactics to reduce opioid-related harm.
In Conversation With… David Juurlink, MD, PhD
Opioids and Patient Safety, May 2017
Dr. Juurlink is professor of medicine, pediatrics, and health policy at the University of Toronto, where he is also director of the Division of Clinical Pharmacology and Toxicology. We spoke with him about the opioid epidemic and strategies to address this growing patient safety concern.
In Conversation With… Mark Chassin, MD, MPP, MPH
New Thinking About High Reliability, April 2017
Dr. Chassin is president and chief executive officer of The Joint Commission. He is also president of the Joint Commission Center for Transforming Healthcare, a center he began to promote high reliability and transformative practice. We spoke with him about new thinking in high reliability.
In Conversation With… Kathleen Sutcliffe, MN, PhD
Professor Sutcliffe is a Bloomberg Distinguished Professor of Business and Medicine at Johns Hopkins University. She studies organizational adaptability, reliability, resilience, and safety in health care. We spoke with her about high reliability in health care organizations.
Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety
with commentary by Sara J. Singer, MBA, PhD, Approaching Safety Culture in New Ways, March 2017
This piece discusses the importance of strengthening safety culture in health care and offers insights for organizations seeking to achieve culture change.
In Conversation With… Mary Dixon-Woods, DPhil
Approaching Safety Culture in New Ways, March 2017
Dr. Dixon-Woods is RAND Professor of Health Services Research at Cambridge University, Deputy Editor-in-Chief of BMJ Quality and Safety, and one of the world's leading experts on the sociology of health care. We spoke with her about new ways to approach safety culture.
Measuring and Responding to Deaths From Medical Errors
The toll of medical errors is often expressed in terms of mortality attributable to patient safety problems. In 2016, there was considerable debate regarding the number of patients who die due to medical errors. This Annual Perspective explores the methodological approaches to estimating mortality attributable to preventable adverse events and discusses the benefits and limitations of existing approaches.
New Insights About Team Training From a Decade of TeamSTEPPS
with commentary by David P. Baker, PhD; James B. Battles, PhD; Heidi B. King, MS, Update on Teamwork, February 2017
This piece outlines 10 insights about team training in health care learned from experience with the AHRQ-supported teamwork training program, TeamSTEPPS.
In Conversation With… Amy C. Edmondson, PhD, AM
Update on Teamwork, February 2017
Dr. Edmondson is the Novartis Professor of Leadership and Management at Harvard Business School. She is an expert on leadership, teams, and organizational learning. We spoke with her about the role of teamwork in health care and why it is becoming increasingly important.
Workplace Safety in Health Care
with commentary by Ross W. Simon and Elena G. Canacari, RN, Workplace Safety, January 2017
This piece explores how a team at Beth Israel Deaconess Medical Center combined tools and techniques used in manufacturing along with continuous improvement to develop a process to identify, prioritize, and mitigate hazards in health care settings.
In Conversation With… Paul H. O'Neill, MPA
Workplace Safety, January 2017
Mr. O'Neill served as the United States Secretary of the Treasury under President George W. Bush and, prior to that, chairman and CEO of Alcoa. We spoke with him about workplace safety and its relationship to patient safety and organizational excellence.
Patient Safety and Opioid Medications
with commentary by Urmimala Sarkar, MD, and Kaveh Shojania, MD, 2016
Opioids are known to be high risk medications, and concerns about patient harm from prescription opioid misuse have been increasing in the United States. This Annual Perspective summarizes research published in 2016 that explored the extent of harm from their use, described problematic prescribing practices that likely contribute to adverse events, and demonstrated some promising practices to foster safer opioid use.
Errors and Near Misses: What Health Care Could Learn From Aviation
with commentary by Carl Macrae, PhD, Root Cause Analysis: What Have We Learned?, December 2016
This piece explores how strategies from aviation, such as just culture and monitoring technologies, can be applied in health care to improve patient safety.
In Conversation With... James P. Bagian, MD, PE
Root Cause Analysis: What Have We Learned?, December 2016
Dr. Bagian is Director of the Center for Healthcare Engineering and Patient Safety at the University of Michigan, and a former astronaut. He co-chaired the team that produced the influential NPSF report entitled, RCA2: Improving Root Cause Analyses and Actions to Prevent Harm.
In Conversation With… Derek Feeley
New Leaders in Safety and Quality, November 2016
In January 2016, Mr. Feeley, a leading health care administrator from Scotland, became the third President and CEO of the Institute for Healthcare Improvement (IHI), probably the most influential organization of its kind. We spoke with him about his work at IHI to improve health care quality and safety.
In Conversation With… Andrew Bindman, MD
Dr. Bindman, an expert in health policy in underserved populations, was appointed as director of the Agency for Healthcare Research and Quality (AHRQ) in May 2016. We spoke with him about his new role at AHRQ.
Health Care Data Science for Quality Improvement and Patient Safety
with commentary by Alvin Rajkomar, MD, Big Data and Patient Safety, October 2016
This piece explores the role for a clinician data scientist in utilizing clinical datasets to improve health care quality and safety.
In Conversation With… Richard Platt, MD, MSc
Big Data and Patient Safety, October 2016
Dr. Platt is Professor and Chair of the Harvard Medical School Department of Population Medicine. We spoke with him about big data and patient safety.
Telemedicine and Patient Safety
with commentary by Stephen Agboola, MD, MPH, and Joseph Kvedar, MD, Telemedicine and Patient Safety, September 2016
This piece explores benefits and safety concerns associated with the increased adoption of telemedicine services.
In Conversation With… Reed V. Tuckson, MD
Telemedicine and Patient Safety, September 2016
Dr. Tuckson is President of the American Telemedicine Association. We spoke with him about telemedicine and patient safety.
Safety In Dentistry
with commentary by Rachel Badovinac Ramoni, DMD, ScD; Muhammad Walji, PhD; and Elsbeth Kalenderian, DDS, MPH, PhD, Patient Safety in Dentistry, July/August 2016
This piece examines patient safety issues unique to dental care along with strategies to reduce risks.
In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD
Patient Safety in Dentistry, July/August 2016
Dr. Perea-Pérez is Director of the Spanish Observatory for Dental Patient Safety. We spoke with him about patient safety in dentistry.
Becoming a Certified Professional in Patient Safety—A Pharmacist's Perspective
with commentary by Zahra Khudeira, PharmD, Certification in Patient Safety, June 2016
In this piece, a pharmacist highlights the importance of earning patient safety certification.
Becoming a Certified Professional in Patient Safety—A Registered Nurse's Perspective
with commentary by Karen Frank, DNP, RN, MSHA, Certification in Patient Safety, June 2016
This piece offers a nurse's viewpoint on the benefits of acquiring certification in patient safety.
In Conversation With… Gregg S. Meyer, MD, MSc
Certification in Patient Safety, June 2016
Dr. Meyer is Chief Clinical Officer of Partners Healthcare System, the large Boston-based system that includes Massachusetts General and Brigham and Women's Hospitals. We spoke with him about training and certification in patient safety.
Reducing the Safety Hazards of Monitor Alert and Alarm Fatigue
with commentary by Samantha Jacques, PhD, and Eric Williams, MD, MS, MMM, Alert and Alarm Fatigue, May 2016
This piece describes strategies to reduce alarm fatigue in hospitals, including educating staff and patients, customizing alarm settings, and performing maintenance of lead wires.
In Conversation With... Barbara Drew, RN, PhD
Alert and Alarm Fatigue, May 2016
Dr. Drew is the David Mortara Distinguished Professor of Physiological Nursing and Clinical Professor of Medicine in Cardiology at the University of California, San Francisco. We spoke with her about the perils and prevalence of alert fatigue.
In Conversation With… Thomas J. Nasca, MD, MACP
CLER and I-PASS, April 2016
Dr. Nasca is CEO of the Accreditation Council for Graduate Medical Education, the major accreditor of residency and fellowship training programs, and CEO of ACGME International. We spoke with him about ACGME's Clinical Learning Environment Review (CLER) program and its impact on medical education.
In Conversation With… Amy J. Starmer, MD, MPH
Dr. Starmer is Director of Primary Care Quality Improvement and Assistant Professor of Pediatrics at Boston Children's Hospital and Harvard Medical School. We spoke with her about handoffs and the implementation and findings of the landmark I-PASS study.
In Conversation With… Paul McGann, MD
Federal Organizations in Patient Safety, March 2016
Dr. McGann is the Chief Medical Officer for Quality Improvement at the Centers for Medicare & Medicaid Services (CMS) and the Co-Director of the CMS Partnership for Patients. We spoke with him about his work at CMS and with the Partnership for Patients initiative.
In Conversation With… Richard Kronick, PhD
Dr. Kronick has served as director of the Agency for Healthcare Research and Quality since August 2013, and will be stepping down from the role this month. We spoke with him about AHRQ's efforts to develop measurements and implement improvements in patient safety.
Relationships Between Physician Professional Satisfaction and Patient Safety
with commentary by Mark Friedberg, MD, MPP, Joy in Practice, February 2016
This piece highlights the importance of focusing on physician professional satisfaction as a way to determine potential patient safety hazards and improve health care quality.
In Conversation With…Christine A. Sinsky, MD
Joy in Practice, February 2016
Dr. Sinsky is the Vice President for Professional Satisfaction at the American Medical Association and a primary care physician in Dubuque, IA. We spoke with her about physician professional satisfaction, including its relationship to patient outcomes and safety.
Accountability in Patient Safety
with commentary by Christopher Moriates, MD, and Robert M. Wachter, MD, 2015
While the patient safety world has largely embraced the concept of a just culture for many years, in 2015 the discussion moved toward tackling some of the specifics and many gray areas that must be addressed to realize this ideal. This Annual Perspective reviews the context of the "no blame" movement and the recent shift toward a framework of a just culture, which incorporates appropriate accountability in health care.
Computerized Provider Order Entry and Patient Safety
Computerized provider order entry is a cornerstone of patient safety efforts, and the increasingly widespread implementation of electronic health records has made it a standard practice in health care. This Annual Perspective summarizes novel findings and research directions in computerized provider order entry in 2015.
Burnout Among Health Professionals and Its Effect on Patient Safety
with commentary by Audrey Lyndon, PhD, 2015
Clinician burnout is prevalent across health care settings and may impair clinicians' ability to maintain safe practices and detect emerging safety threats. This Annual Perspective summarizes studies published in 2015, with a particular focus on the relationship between burnout and patient safety, and interventions to address burnout among clinicians.
Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice
with commentary by Hardeep Singh, MD, MPH, Update on Diagnostic Errors, January 2016
This piece discusses momentum in the field of diagnostic error over the past several years (culminating in the recent Improving Diagnosis in Health Care report) and outlines future avenues to ensure progress in diagnostic safety.
In Conversation With… Mark L. Graber, MD
Update on Diagnostic Errors, January 2016
Dr. Graber founded the Society to Improve Diagnosis in Medicine and the journal, Diagnosis. We spoke with him about the recent National Academy of Medicine (formerly Institute of Medicine) Improving Diagnosis in Health Care report, and about diagnostic errors more generally.
Introducing the Redesigned AHRQ Patient Safety Network
with commentary by Robert M. Wachter, MD, Ten years of AHRQ Patient Safety Network: A Window Into the Evolution of the Patient Safety Literature, November 2015
This editorial provides an overview of how PSNet and WebM&M have evolved in the past decade.
In Conversation With… Kaveh Shojania, MD
Ten years of AHRQ Patient Safety Network: A Window Into the Evolution of the Patient Safety Literature, November 2015
Dr. Shojania is Editor-in-Chief of BMJ Quality and Safety and Director of the Centre for Quality Improvement and Patient Safety at the University of Toronto. We spoke with him about the evolution of patient safety research over the past 15 years.
In Conversation With… Lorri Zipperer, MA
Ms. Zipperer was a founding staff member of the National Patient Safety Foundation as their information projects manager and has also been Cybrarian for AHRQ Patient Safety Network since its inception. We spoke with her about the role of librarians in patient safety.
In Conversation With… Vineet Arora, MD, MAPP
Electronic Tools for Patient Safety: Engaging Patients and Providers, September 2015
Dr. Arora is Director of GME Clinical Learning Environment Innovation and Assistant Dean for Scholarship and Discovery at the University of Chicago Pritzker School of Medicine. We spoke with her about the intersection of health information technology and patient safety.
In Conversation With… Eric J. Topol, MD
Dr. Topol is Director of Scripps Translational Science Institute and Editor-in-Chief of Medscape. We spoke with him about his book, The Patient Will See You Now: The Future of Medicine is in Your Hands.
New Insights on Safety and Health IT
with commentary by A. Zach Hettinger, MD, MS; Raj Ratwani, PhD; Rollin J. (Terry) Fairbanks, MD, MS, New Insights on Safety and Health IT, July/August 2015
This piece provides an overview of health IT usability design, including persisting challenges and progress in the field.
In Conversation With… Robert M. Wachter, MD
New Insights on Safety and Health IT, July/August 2015
Dr. Wachter is Professor and the Interim Chairman of the Department of Medicine at UCSF. We talked with him about his new book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age.
In Conversation With… Maureen Bisognano
Organizations Working to Improve Quality and Safety, June 2015
Maureen Bisognano is President and CEO of the Institute for Healthcare Improvement (IHI). We spoke with her about IHI's efforts to improve health care on a global level.
In Conversation With… Christine Cassel, MD
Dr. Cassel, President and CEO of the National Quality Forum (NQF), is a leading expert in geriatric medicine, medical ethics, and quality of care. We spoke with her about NQF's work in developing and utilizing quality measures to improve safety in health care.
Video to Improve Patient Safety: Clinical and Educational Uses
with commentary by Yan Xiao, PhD; Colin F. Mackenzie, MB, ChB; and F. Jacob Seagull, PhD, Using Video to Assess Quality and Safety, May 2015
This piece explores the advantages of using video in clinical practice and health care education to augment safety and quality.
In Conversation With… John D. Birkmeyer, MD
Using Video to Assess Quality and Safety, May 2015
Dr. Birkmeyer is Chief Academic Officer and Executive Vice President at Dartmouth-Hitchcock Medical Center. We spoke with him about his seminal New England Journal of Medicine video study that found a link between practicing surgeons' directly observed technical skills and surgical outcomes.


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Home Wire International Flamengo soccer club fire in Brazil: bad luck or negligence?
Flamengo soccer club fire in Brazil: bad luck or negligence?
RIO DE JANEIRO (AP) – Within hours of a fire at soccer club Flamengo's training facility that would kill 10 teenage players, the club's president called it "the worst tragedy" in the team's 123-year history.
Soccer greats around the world expressed condolences, Rio de Janeiro's mayor declared three days of mourning and the club, Brazil's most popular and one of the most recognizable in Latin America, commemorated the boys during its latest home game on Thursday. Club officials repeatedly said the fire was simply a question of bad luck.
"It was not because of lack of attention and care from Flamengo. These boys are our biggest asset," said Flamengo's CEO Reinaldo Belotti a day after the Feb. 8 blaze. "It was all a succession of events after a catastrophic day for Rio."
But for at least four years before the blaze, the club flouted city and code regulations at the training facility, incurred numerous fines and was the target of a lawsuit by state prosecutors related to the treatment of its academy players and their living quarters, an Associated Press review of city documents and a lawsuit has found. What's more, a material used in the construction of the dorms, polyurethane, could have fueled the fast-moving blaze that engulfed the players, according to fire experts.
The findings raise questions about whether negligence by the team and a collective failure of authorities to regulate the training grounds ultimately played the largest roles in the tragedy.
"This is an irregular construction," city hall spokesman Tiago Costa told The Associated Press when asked about the container-like structures where 26 players were sleeping when fire struck.
Officials have not given an official cause for the blaze, though they have said they are investigating the possibility that an air conditioning unit caught fire after a power surge.
For years, the club had its academy players, teens between the ages of 14 and 16 identified as potential future professionals, sleeping in quarters that were never approved by the city. In fact, the area that burned was licensed as a parking lot, not a dormitory.
The most recent city license for the club, from April of last year, had no mention of sleeping quarters anywhere on the sprawling complex known as Ninho de Urubu in western Rio de Janeiro.
Since the dormitory didn't officially exist, firefighting officials said they did not inspect or certify it.
The burned area "was not part of the security plan against fire or panic presented by the club and approved by the Fire Department," state firefighters said in a statement to the AP.
Bernardo Monteiro, a Flamengo spokesman, told the AP that the team had used the containers since 2010. He said there was one exit and the structures had fire extinguishers and smoke detectors, though could not say how many.
The existence of the containers was well known by authorities.
In March 2015, Rio state prosecutors filed a suit against the club demanding the closure of the training facility unless several irregularities were rectified.
Prosecutors demanded the club "address all the inherent peculiarities in the care of children and adolescents, from the pedagogical, social, psychological and medical all the way to the adequacy of accommodation facilities," read the suit.
The suit also called for the facility to be closed until there was "proof of compliance with the conditions imposed by the Fire Department, Civil Defense and City Hall," and any infraction to be met with a $27,000 fine.
Nearly four years later, no decision was made on the case – until Wednesday, five days after the deadly fire.
In a blistering ruling, Judge Pedro Henrique Alves said that Flamengo hadn't just failed to address the demands in the suit, but also "didn't even inform the court" of other changes it had made since the suit was filed.
Flamengo "used as lodging for adolescents containers that, unfortunately, caught fire, taking the lives of 10 (players) and injuring three others," he wrote, adding that children and adolescents were barred from entering the facility until further notice. Any infraction would result in a US$2.8 million fine.
The club was also frequently in the crosshairs of city officials: it was fined 31 times over the last few years for licensing violations, and in October 2017 the training facility was temporarily closed.
"If you are fined 30 times, you can't keep postponing and get 20 more. Something has to be done," Arthur Antunes Coimbra, one of the club's most famous players known as "Zico," told Globo's SporTV this week.
Police have opened an investigation and say that criminal charges are possible.
Meanwhile, the company that made the dormitory, NHJ do Brasil, told the AP in a statement that its structures were made in accordance with the latest international standards. It also said the structure that burned was made of a metallic shell and lined on the inside with galvanized thermal acoustic panels that had a polyurethane core that was "self-extinguishing."
"In other words, the modules are made of metal and filled in with anti-inflammable material," said the company, which declined to answer whether the structures came with fire extinguishers, smoke detectors or air-conditioning units.
Polyurethane is an expanded plastic, or plastic injected with air, that is widely used in construction. While it can be treated with retardant, it can also burn very quickly if it catches fire from another source, three fire experts not involved in the investigation told the AP.
"Polyurethane foam used in this way is a cheap technology and dangerous from a fire protection perspective," said David Howitt, an emeritus professor at the University of California at Davis and expert in combustion. "These so-called 'fire retardant' foams are not retardants to the degree that the manufacturers suggest and are frequently grossly overstated."
Robert Solomon, a fire engineer with the Quincy, Massachusetts-based National Fire Protection Association, reviewed security camera video of the blaze and pictures of the aftermath. The images show drooping metallic roofs, mangled black panels and many objects so badly charred that they are indistinguishable.
Solomon said he found at least three red flags: only one exit, bars on some of the windows and an apparent lack of basic protective tools like smoke alarms. And the video footage appeared to show "flashover," when every combustible thing in an area is burning, he said. Flashover temperatures, upward of 1,900 Fahrenheit (1,037 Celsius), are so high that a person can become paralyzed, even if the flames are not touching them.
"At that point, it's like being trapped in a prison with no way to escape," said Solomon.
After the fire, the Rio state prosecutor's office formed a task force focused on financial compensation of the victims' families. Many families whose children stay at academies are low income, and sometimes live far from the team.
Some family members and friends of victims have quietly questioned the safety measures the team had in place.
"There should have been an emergency door. There wasn't," said Severino Fausto Santana, while attending the funeral of 15-year-old nephew Samuel Thomas de Souza Rosa. "That's why the 10 (boys) died."
But for the most part, families have remained quiet, either declining to speak about Flamengo or lauded the club's effort at a time of great grief.
"Flamengo is very useful and helping with everything," said Sergio Morikawa, who was not the biological father but was helping to raise 15-year-old Vitor Isaias, one of the kids who died. "I don't want to judge, work myself up or blame anyone."
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Flamengo soccer club president Rodolfo Landim, right, attends a mass in honor of the 10 teenage soccer players who were killed by a fire at the Flamengo training center last Friday, in Rio de Janeiro, Brazil, Friday, Feb. 15, 2019. The victims were between 14 and 16 years old. Police are still investigating what caused the fire. (AP Photo/Silvia Izquierdo)
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