Recent eLetters

Displaying 1-10 letters out of 61 published

  1. Evidence-based E-Health Policy - Vitally Important but not a New Call

    The editorial from Sheikh, Atun, and Bates is welcome in flagging up a key issue in the context of England and the US. However, it is not a new issue, and it is disappointing that they do not acknowledge prior and concurrent work.

    The need for, and challenges impeding, evaluation of health information systems have been flagged up much earlier, e.g. Rigby 1999; 2001. Both the European Federation for Medical Informatics (EFMI) and the International Medical Informatics Association (IMIA) have groups which have followed up this theme. Ammenwerth instigated a European workshop which inspired a significant work programme (Ammenwerth et al, 2004), and led to production of reporting standards adopted by the EQUATOR network (Talmon et al, 2009)and guidelines (Nyk?nen et al, 2011) which have been fully elaborated (Brender et al, 2013).

    The specific dual challenges behind the editorial by Sheikh, Atun and Bates are the penchant for politicians to decree policy outside their technical knowledge in order to appear progressive, and the generic need for evidence-based policy in health informatics. This latter too has recently been addressed - generically by a dedicated edition of the IMIA Year Book (S?rousi et al, 2013) which included a summary of the concerted actions of a decade (Rigby et al, 2013); and in the context of developing countries by WHO (2011) and through a joint WHO-IMIA Programme (IMIA, 2012).

    Moving to evidence-based health informatics policy is vital for effectiveness, efficiency, safety, and enhanced health care delivery and outcomes. Such an approach faces challenges as it cuts across the perceived autonomy of politicians, and the worrying scant regard for a scientific evidence base of some sectors of the supplier industry, while evaluation to produce the evidence continually faces impediments as described. It is therefore vitally important that all innovators and activists work collaboratively to progress the issues.

    Michael Rigby

    Rigby M (1999) Health Informatics as a Tool to Improve Quality in Non -acute Care - New Opportunities and a Matching Need for a New Evaluation Paradigm; International Journal of Medical Informatics, 56, 1999, 141-150.

    Rigby M (2001.)Evaluation: 16 Powerful Reasons Why Not to Do It - And 6 Over-Riding Imperatives; in Patel V, Rogers R, Haux R (eds.): Medinfo 2001: Proceedings of the 10th. World Congress on Medical Informatics, IOS Press, Amsterdam, 2001, 1198-1202.

    Ammenwerth E et al (2004). Visions and strategies to improve evaluation of health information systems: Reflections and lessons based on the HIS-EVAL workshop in Innsbruck. International Journal of Medical Informatics, 2004 Jun 30; 73(6):479-91.

    Talmon J. et al (2009. STARE-HI - Statement on Reporting of Evaluation Studies in Health Informatics; International Journal of Medical Informatics; 78 2009, 1, 1-9.

    Nyk?nen P. (2011). Guideline for good evaluation practice in health informatics (GEP-HI); International Journal of Medical Informatics, 80, 815-827, 2011.

    Brender J (2013). STARE-HI - Statement on Reporting of Evaluation Studies in Health Informatics: explanation and elaboration. Applied Clinical Informatics, 2013; 4: 331-358.

    S?rousi B, Jaulent M-C, Lehmann CU (eds.) (2013). Evidence-based Health Informatics - IMIA Yearbook of Medical Informatics 2013; 34-46, Schattauer, Stuttgart, 2013.

    Rigby M. et al (2013). Evidence Based Health Informatics: 10 Years of Efforts to Promote the Principle - Joint Contribution of IMIA WG EVAL and EFMI WG EVAL; in S?rousi B, Jaulent M-C, Lehmann CU. Evidence-based Health Informatics - IMIA Yearbook of Medical Informatics 2013; 34-46, Schattauer, Stuttgart, 2013.

    WHO(2011)Call to Action on Global eHealth Evaluation - Consensus Statement of the WHO Global eHealth Evaluation Meeting, Bellagio, September 2011; available from action-global-ehealth-evaluation

    IMIA(2012). beijing-president-WHO.pdf

    Conflict of Interest:

    MR is retired but undertakes periodic paid and pro bono activities in health information, health policy, and related subjects.

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  2. Paperlite patient record, are we ready.

    Stephanie et al has produced some very interesting observations about the impact of electronic medical records on patient-doctor communication. Recent investigations into the social care system in the light of child abuse enquiries depicted that professionals spend far too much time on making records rather than face to face meetings with families and children. More trusts in the NHS are adapting paper light patient record to improve efficiency and patient care. However, we conducted an audit in a medium secure unit in Manchester to evaluate the efficiency of electronic system and staff ability to access important clinical documents. The results showed that time spent to find these documents was significantly more on electronic record than the paper record which raises questions about the efficiency of electronic patients record.

    Conflict of Interest:

    None declared

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  3. Identifying system failures by incident reporting systems

    With respect to the scientific article of Franklin et al. (BMJ Qual Saf 2014;0:1-8.doi:10.1136/bmjqs-2013-002572) I would like to address two further issues concerning the learning and reporting system in general as well as defense strategies in order to prevent errors in administration of intrathecal chemotherapy.

    The amount of nine million incident reports in NHS is very impressive when compared to other reporting systems within European countries. NHS- reports over a period of 11 years implicates that more than 2.000 incidents have to be sent per day by healthcare professionals to the National Reporting and Learnings System (NRLS). According to published data (1) for England and Wales more than 153.000 out of 1.45 million incidents of the type "medication" were reported from Oct 2012 to Sep 2013. Severe harm or deaths were scored in 10.781 cases (0.7% per year). Errors in administration of intrathecal chemotherapy have been reported in 38 times over a decade within NHS. Compared to the German Medicine (2) (between 1995 to 2005 528 suspected adverse concerning vinca alkaloids) or the European Medicine Agency (approximately 350 documented cases), the number of reported events seems low within NHS. Nevertheless, reporting of patient safety incidents is a subjective and voluntarily exercise and on a very high level within NHS.

    In many other European countries, homogenous reporting and learning system are lacking so far. In Austria for example, a NLRS is implemented and accessible for the public (3), whereas hospitals run various reporting and learning systems without national coordination and evaluation. Within four years of being online, in total 344 incidents were reported (4 reports per week) to the NLRS and thereof, 21% were scored implicating therapeutic harm.

    NHS is in a leading role concerning NRLS and the level of patient safety culture with respect of reporting events as well as their open- minded way in presenting statistics to the public is unique. Concerning the data pool, NHS could support others in the development of guidelines and patient safety practices in order to overcome the most prominent hazards.

    The authors presented a comprehensive list of defense strategies to prevent vinca alkaloids errors. Furthermore, we suggest, in line with the Evidence-Based Practice guideline (4), team trainings and in analogy to the WHO-Surgical Safety Checklist a team-time-out before administration of high-risk medication. Author: Name:Dr. Gerald Sendlhofer Title/position: 1) Head 2) Scientific co-worker Affiliations: 1) Department of Quality and Risk Management, University Hospital Graz, Graz, Styria, Austria 2) Division of Plastic, Aesthetic and Reconstructive Surgery, Medical University Graz, Styria, Austria

    (1) summaries/?entryid45=135253 (accessed 7 May 2014)

    (2) (accessed 7 May 2014)

    (3) (accessed 7 May 2014)

    (4) Schulmeister L. Preventing vincristine administration errors: does evidence support minibag infusions? dOI: 10.1188/06.CJON.271-273

    Conflict of Interest:

    None declared

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  4. Adaptation in French oncology practice guidelines to patients: patient versions and patient involvement in the development process of guidelines

    While Clinical Practice Guidelines (CPGs) have gained momentum to inform evidence-based practices, less investment has been made to use CPGs to support evidence-informed patient choice. The qualitative study by van der Weijden et al. shows a consensual vision of the need for and benefice of adapting CPGs into relevant patient versions to integrate patients' preferences in clinical decision-making. While we agree with the authors' conclusions and the suggested so-called generic strategy in principle, we would like to comment the proposed approach from the French perspective of CPG development and shared decision-making (SDM). Doing so, we respond to a major limitation stressed by Weijden et al. stemming from the fact that the results reflect merely an anglo-saxon perspective. Examination of non-adherence to practice guidelines of the French oncology guidelines program "Standards, Options, Recommendations" (SOR) established in 1993 by the National French Federation of Comprehensive Cancer Centres,?1? revealed that diverging patient values and preferences may hamper guideline adherence. This observation has led to two developments we would like to share here: the development of patient versions of SOR CPGs, and cancer patients' involvement in the development process of SOR CPGs.

    To improve patients' involvement in decision-making, participants interviewed by the authors suggested translating CPG reports into lay terminology useful to professionals and patients. Such an approach has been implemented within the SOR program since 1999. It is based on an interdisciplinary working group (clinicians, methodologists, psychologists, linguist, anthropologist) and a triangulation of methods to involve cancer patients, combining focus groups, semi-structured interviews and postal surveys. We translated the SOR CPGs into patient versions in more than twenty cancer sites. An innovative linguistic approach was used to ensure that the information provided is adapted to patients' health literacy. A list of generic questions that patients may ask to health professionals was developed to support patient-centered communication during the medical encounter and encourage SDM,?2?. As was pointed out by Weijden et al., patient involvement in the development of SOR patient versions let us to the awareness that SOR CPGs did not adequately incorporate patient preferences, in particular the presentation of treatment options, their benefits and risks. Consequently, we set up in 2003 a process to involve cancer patients in the development of these guidelines,?3?. Our approach consisted in a cancer patient panel reviewing the guideline draft and feeding back their comments and recommendations to the guideline panel. Our approach allowed the patient group to formulate a list of key recommendations from their perspective to be addressed in the final guideline, and to point out situations most appropriate for SDM. Patients stressed the importance of improved communication and information to facilitate patient participation in the decision-making process.

    Based on our experience, we hypothesize that CPGs can be adapted to facilitate the integration of patients' preferences in clinical decision- making. The French experience suggests that the consensual 'generic' strategy proposed by the authors is applicable beyond the anglo-saxon context of their study and provide a practical example of how the proposed approaches could be translated within existing guideline programs. Recent French institutional initiatives highlight a growing awareness of the need to improve connection between CPGs, patient decision aids and SDM,?4-5?.

    Developing and updating high quality CPGs and patient decision support tools require substantial time, expertise and resources. We support the author's view that it is preferable to adapt existing CPGs rather than developing new patient decision support tools. Such approaches may foster the integration of research evidence and individual preferences in health care decisions, avoid duplication of effort and enhance efficiency. Further research is needed to assess the impact on clinical practice of such approaches.


    1. Fervers B, Hardy J, Philip T. ? Standards, Options and Recommendations ?. Clinical Practice Guidelines for cancer care from the French National Federation of Cancer Centres (FNCLCC). Br J Cancer 2001; 84(Suppl2):1-92.

    2. Fervers B, Leichtnam-Dugarin L, Carretier J, Delavigne V, Hoarau H, Brusco S, Philip T. The SOR SAVOIR PATIENT project--an evidence-based patient information and education project. Br J Cancer. 2003 Aug; 89 Suppl 1:S111-6.

    3. Fervers B, Bataillard A, Carretier J, Kelson M. Involving cancer patients in clinical practice guidelines (CPGs) development in a French guidelines program: What are the key issues? Journal of Clinical Oncology, 2006 ASCO Annual Meeting Proceedings (Post-Meeting Edition).Vol 24, No 18S (June 20 Supplement), 2006: 16029.

    4. Haute Autorite de Sante (Health National Authority). Etat des lieux. Patient et professionnels de sante : decider ensemble. Concept, aides destinees aux patients et impact de la decision medicale partageee, octobre 2013. http://www.has- 10/12iex04_decision_medicale_partagee_mel_vd.pdf

    5. Cnamts (National Health Insurance Fund). Ameliorer la qualite du systeme de sante et maitriser les depenses : propositions de l'Assurance maladie pour 2014. Rapport au ministre charge de la securite sociale et au Parlement sur l'evolution des charges et des produits de l'Assurance maladie au titre de 2014 (loi du 13 aout 2004), juillet 2013.

    Conflict of Interest:

    None declared

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  5. Re:Any value of Early Warning Systems must rely on the prevalence of the conditions being sought

    In reply to Bewley's response to our paper, we acknowledge that a number of studies have assessed the extent of major obstetric complications as higher than that cited in the RCOG publication [1-5]. Definitions as well as rate estimation of maternal morbidity vary widely across studies [1]. However, the premise of our paper was not to minimise the scale and severity of the problem of maternal morbidity, but to explore the logic and perceived value of one particular safety solution, the MEOWS. In the light of our findings, we still conclude that the complexity of managing risk and safety within the maternity pathway, the associated opportunity costs of MEOWS and variation in implementation call into question its current role for routine use. We reiterate our belief that there is an urgent need for further research to validate the MEOWS for the maternity population.

    References 1. Zhang WH, Alexander S, Bouvier-Colle MH, Macfarlane A; MOMS-B Group. Incidence of severe pre-eclampsia, postpartum haemorrhage and sepsis as a surrogate marker for severe maternal morbidity in a European population- based study: the MOMS-B survey. BJOG 2005;112:89-96. 2. Maternal Critical Care Working Group. Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman. London: RCOG Press, 2011 3. Waterstone M, Bewley S, Wolfe C. Incidence and predictors of severe obstetric morbidity - a case control study. Br Med J 2001;322:1089-94 4. Brace, Victoria, Gillian Penney, and Marion Hall. Quantifying severe maternal morbidity: a Scottish population study. BJOG: An International Journal of Obstetrics & Gynaecology 2004;111:481-484 5. Zanconato, Giovanni, et al. Severe maternal morbidity in a tertiary care centre of northern Italy: a 5-year review. Journal of Maternal-Fetal and Neonatal Medicine 2012;25:1025-1028.

    Conflict of Interest:

    None declared

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  6. Any value of Early Warning Systems must rely on the prevalence of the conditions being sought

    Mackintosh et al. have made a useful contribution to the literature about pregnant and parturient's safety (1). The purpose of an Early Warning System (EWS) is to take action before deterioration that may require multiorgan support in intensive care. The ethnographic technique revealed many perceived benefits of a simple, graphic monitoring tool that empowered escalation of concerns. The research team highlighted inconsistencies in implementation of EWS, multiple competing charts for antenatal, intrapartum, postnatal and high dependency care and also resistance to medicalising normal birth. However, if EWSs do 'work' (which may yet need proving), their value will also depend on the nature and extent of problems which should not be understated.

    The authors state "for every [maternal] death, nine women develop major obstetric complications including haemorrhage, infection, hypertensive disorders and thromboembolism". The RCOG reference cited is itself in error as it reported the numbers of women in the UK utilising critical care settings, (260 vs 14/ 100 000 maternities, a ratio of 19 high dependency and intensive care admissions to each death) (2). The report explains how definitions of severe morbidity vary, but that the number of major obstetric complications may be as high as 86-fold the number of deaths (1 200/ 100 000 maternities) (2,3). EWSs may also have an impact upstream on moderate morbidity with its commoner human and financial costs.


    1. Mackintosh N, Watson K, Rance S, Sandall J. Value of a modified early obstetric warning system (MEOWS) in managing maternal complications in the peripartum period: an ethnographic study. BMJ Qual Saf 2013;0:1-9. doi:10.1136/bmjqs-2012-001781

    2. Maternal Critical Care Working Group. Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman. London: RCOG Press, 2011:4

    Conflict of Interest:

    None declared

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  7. Separating fact from opinion - A response to 'The science of human factors: Separating fact from fiction'

    In their paper 'The science of human factors: separating fact from fiction', Russ et al present a description of the human factors (HF) discipline, and discuss several cases where the science of HF has been misapplied in healthcare [1].

    On examining some of the examples of misapplication they provide, it became apparent that in most cases the term 'human factors' was used to describe factors relating to human behavior (e.g. communication), rather than the scientific discipline [2, 3]. The research did not purport to adopt a HF methodology or stance. Are these really misconceptions about HF science?

    Russ et al also provide examples of studies that refer to HF science but emphasize the failures of people. They describe this research as 'counterproductive' but the work they cite adopted HF methods and exposed some interesting aspects of human behaviour. For example, consultation with clinicians revealed that user acceptance of technology was critical for successful implementation of electronic medication management [4]. In another study (of which I am an author), review of medication charts revealed that misuse of an electronic prescribing system was associated with the generation of unnecessary computerized safety alerts [5]. We concluded that both system design and inadequate training may have contributed to system misuse.

    In their viewpoint, Russ et al, discuss training at some length and provide an overview of where training is an appropriate versus inappropriate HF technique for improving patient safety [1]. This discussion interested me as their table (Table 1) referred to few studies examining the effectiveness of training. They explain that training is not appropriate if it is designed to address a type of error committed by multiple users, as wide-spread error indicates a mismatch between system design and human characteristics. Identification of mismatch between design and human capabilities/limitations is at the crux of the HF discipline and is undoubtedly an important undertaking. But is it not also possible that all users received the same (ineffective) training, and so all made the same types of error? In the same way, Russ at al suggest that training is not appropriate when the goal is for individuals to stop using technologies in the wrong way. But can it not be that correct use of the system was not effectively demonstrated during training, and so users were not aware that more efficient use was possible?

    I agree with Russ et al in that additional training should only be considered following an evaluation of system design, but what if design is intended to break free from previous iterations, with the aim of transforming or revolutionizing a task? There exists a tension between designing systems that replicate current processes and so integrate quickly into clinical practice versus designing systems that allow tasks to be completed in more efficient ways, but which require a change in work and cognitive processes and so necessitate a greater level of training. Russ et al were quick to criticize previous research but by taking a closer look there is value in all HF applications to healthcare.


    1 Russ AL, Fairbanks RJ, Karsh B-T, Militello LG, Saleem JJ, Wears RL. The science of human factors: separating fact from fiction. BMJ Quality & Safety. 2013 April 16, 2013.

    2 Cahan MA, Starr S, Larkin AC, Litwin DM, Sullivan KM, Quirk ME. Transforming the culture of surgical education: Promoting teacher identity through human factors training. Archives of Surgery. 2011;146(7):830-4.

    3 Rosenstein AH, O'Daniel M. Impact and Implications of Disruptive Behavior in the Perioperative Arena. Journal of the American College of Surgeons. 2006;203(1):96-105.

    4 Abrams H, Carr D. The Human Factor: Unexpected Benefits of a CPOE and Electronic Medication Management Implementation at the University Health Network. Healthcare Quarterly. 2005;8(Sp):94-8.

    5 Baysari MT, Reckmann MH, Li L, Day RO, Westbrook JI. Failure to utilize functions of an electronic prescribing system and the subsequent generation of 'technically preventable' computerized alerts. Journal of the American Medical Informatics Association : JAMIA. 2012 Nov 1;19(6):1003-10.

    Conflict of Interest:

    None declared

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  8. We need to teach leadership and quality improvement to all doctors, not just a select few.

    We read with interest and agreement the editorial by Claire Lemur and Fiona Moss(1). We very much concur with the point that we have to engage the next generation of clinicians in quality improvement to ensure the future of healthcare. In the article several leadership programmes are mentioned and in addition we would add the NHS Medical Directors Clinical Fellow Scheme(2). However all of these schemes involve a small number of junior doctors rather than the whole. They represent the icing but it is really the 'cake' that we must address.

    In the Severn Deanery we have been running a structured, supported quality improvement programme for the Foundation Year One (FY1s) doctors. Starting four years ago in one hospital this now involves almost half of the 280 FY1s in the deanery, and we plan to include all by 2015. The FY1s chose the project that they feel is most relevant to them (i.e. weekend handover, discharge summaries etc) and then run the project using The Model for Improvement throughout their first year supported by mentors (often who are junior doctors themselves). It has been hugely successful. The only impediments to the further spread has been finding engaged permanent staff with sufficient quality improvement knowledge to mentor and support projects and a structure within the Hospital management to facilitate and recognise the innovations that result; there has been no problems with the enthusiasm and motivation from the juniors themselves. It will only be by up skilling and engaging the 'cake' that we will be able to prepare our future workforce for the task ahead.

    1. Lemer C, Moss F. Patient safety and junior doctors: are we missing the obvious? BMJ Qual Saf 2013;22(1):8-10.

    2. Coltart CE, Cheung R, Ardolino A, Bray B, Rocos B, Bailey A, et al. Leadership development for early career doctors. Lancet 2012;379(9828):1847-9.

    Conflict of Interest:

    None declared

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  9. Re: Harnessing the cloud of patient experience: using social media to detect poor quality healthcare

    January 31, 2013

    To the editors:

    We were pleased to read the recent article by Greaves et al.1 outlining new methodological techniques to analyze patients' online ratings of care. We agree with the authors that social media websites represent a wealth of first-hand patient experiences with health and healthcare, but have largely remained untapped by biomedical researchers - especially to gain new insights into how to improve clinical care. We concur that "big data" techniques such as machine learning and natural language processing can be extremely powerful to synthesize the large amount of textual data on these sites.

    However, our previous work has also suggested the importance of traditional research methods applied to social media content. In particular, qualitative analysis adds perspective to patients' online dialogue where big data mining techniques perhaps cannot. In a qualitative examination of primary care provider ratings on Yelp,2 we analyzed 712 reviews of 455 doctors in four large urban areas (Chicago, New York, Atlanta and San Francisco). We found that these provider ratings often reflected the entire visit experience (i.e., parking, wait times, front desk staff) rather than focusing solely on the clinical encounter with the provider. Similarly, we recently qualitatively coded over 450 Twitter messages about cancer screening,3 and found that miscellaneous tweets such as jokes or popular culture references could be distinguished from the rich information about personal patient experiences with pap smears or mammograms. In both instances, these nuances in the online content may have been missed by applying data mining or natural language processing alone.

    Therefore, we advocate using mixed methods approaches to analyzing social media content about health and healthcare experiences, as these techniques are inherently complementary to one another. Big data approaches allow researchers to examine millions of messages to uncover trends and overall sentiment in the online content, as well as the potential to rank the prevalence of specific discussion topics on social media sites. However, in combination with qualitative analysis of a carefully selected subsample of online content, the textual data can be interpreted in light of additional context - allowing researchers both breadth and depth in their work.

    Moreover, not only should we aim to understand patient values and preferences from the large amounts of publicly available dialogue on social media, but we should also look to online social media as a means to directly engage in this dialogue with patients. Because of the ease of use and the speed of information dissemination, online social media channels have become a cornerstone of everyday life, transforming the ways that society shares ideas and beliefs, news, and information about products and services among individuals and organizations. To be truly patient-centered, healthcare providers and systems should play an active role in communicating important health and healthcare messages through the channels in which growing numbers of patients are already engaged.

    Courtney R. Lyles, PhD & Urmimala Sarkar, MD, MPH University of California San Francisco, Division of General Internal Medicine

    References 1. Greaves F, Ramirez-Cano D, Millett C, Darzi A, Donaldson L. Harnessing the cloud of patient experience: using social media to detect poor quality healthcare. BMJ quality & safety 2013. 2. Lopez A, Detz A, Ratanawongsa N, Sarkar U. What patients say about their doctors online: a qualitative content analysis. Journal of general internal medicine 2012;27(6):685-92. 3. Lyles CR, Lopez A, Pasick R, Sarkar U. "5 Mins of Uncomfyness Is Better than Dealing with Cancer 4 a Lifetime": an Exploratory Qualitative Analysis of Cervical and Breast Cancer Screening Dialogue on Twitter. Journal of cancer education : the official journal of the American Association for Cancer Education 2012.

    Conflict of Interest:

    None declared

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  10. Engaging junior doctors in patient safety: Don't forget the basics

    We read the study by Durani et al (1) and the accompanying editorial (2) with great interest. Aspiring to engage junior doctors in the safety and quality movement is a noble aim but in doing so it is essential to consider the influences of both the formal (explicit) curriculum and the informal ('hidden') curriculum on doctors in training. We feel that whilst Durani et al's questionnaire may be useful to chart temporal trends in junior doctors' knowledge and attitudes in patient safety, we would caution against using subtle differences uncovered in trainees' responses to inform the subsequent development of educational interventions. To do so risks 'over-engineering' approaches to patient safety education and neglecting the basics.

    Our experience of implementing sustainable patient safety training across a Foundation School ('Lessons Learnt: Building a Safer Foundation')(3) has revealed two core ingredients for engaging junior doctors in safety and quality improvement - training providers as a minimum must ensure i) a safe environment for junior doctors to raise and act on safety concerns and ii) basic instruction and opportunities in patient safety and quality improvement for all junior doctors.

    First and foremost, we argue that in order to engage junior doctors in safety improvement, above all, they need to feel safe in the environment within which they work. Whilst informal discussions of safety and quality issues by junior doctors are commonplace in the 'Doctors' Mess' and at other social gatherings, structured and protected opportunities to do so within teaching programmes are severely lacking.

    Moreover, whilst leadership and quality improvement schemes described by Lemer et al(2) are laudable, they invariably appeal to a self-selected group and are not always accessible to all. In the UK, latest guidance by the General Medical Council emphasises the duty of doctors in raising and acting on concerns about patient safety(4) and that leadership and management is a core role of all doctors,(5) not reserved for the privileged few. To ensure equity of opportunity and to fulfil the regulator's standards we need to ensure the provision of basic training and opportunities for junior doctors across both the domains of patient safety and leadership.

    Through providing basic instruction in patient safety and integrating facilitated case-based discussions of patient safety incidents (PSIs) within the teaching programme, we have successfully created a springboard for Foundation trainees' engagement in safety and quality improvement.(3) Importantly, trainees are not passive recipients of the intervention, rather active collaborators with trainee 'Leads' at each site leading local delivery of the programme and rising to the challenge of peer- leadership. Whilst we do not claim that our programme is a panacea for engaging junior doctors in quality and safety, we do feel it is an important first step in promoting wide-scale clinical engagement in the quality movement.

    Conflict of Interest:

    The authors are part of a team who developed, implemented and evaluated 'Lessons Learnt: Building a Safer Foundation' - a patient safety training programme for Foundation trainees in collaboration with the North Western Deanery and the Imperial Centre for Patient Safety and Service Quality. The programme won the BMJ Excellence in Healthcare Education Award 2012.

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