Most Intensive Care Units (ICU) collect comprehensive data relating
to patient demographics, diagnoses and complications and some use this
information to benchmark and guide quality improvement activities aimed at
improving patient outcomes and reducing iatrogenic complications. Ayas
et. al. are to be commended for using routine information they collect in
an attempt to identify trends and possible contributing factors t...
Most Intensive Care Units (ICU) collect comprehensive data relating
to patient demographics, diagnoses and complications and some use this
information to benchmark and guide quality improvement activities aimed at
improving patient outcomes and reducing iatrogenic complications. Ayas
et. al. are to be commended for using routine information they collect in
an attempt to identify trends and possible contributing factors to one of
the potential complications related to insertion of Central Venous
Catheters (CVCs), development of a pneumothorax. Their retrospective
review did not confirm their suspicions that the incidence of pneumothorax
would increase with the introduction of new trainees to their area, which
is surprising, however they have suggested that decreased supervision as
the ICU rotation progresses may contribute to this.
CVCs are widely used in ICUs around the world, and pneumothoraces are a
significant potential complication of insertion of CVCs into the internal
jugular and subclavian veins (SCV). There is high level evidence to
support the insertion of CVCs into neck veins, particularly the SCV, as
opposed to femoral veins to reduce the incidence of blood stream
infections that contribute to significant morbidity and mortality, and
increased length and cost of hospital stay.1
Sheretz et. al. demonstrated that providing targeted training for
physicians in relation to methods to reduce infection related to vascular
device insertion resulted in improved knowledge and retention that
translated into practice. In their study, compliance with evidence based
procedures improved and resulted in a reduction in the incidence of CVC
bloodstream infections. They provided a detailed cost-benefit analysis of
their training program that supports such an approach to improving quality
and safety of patient care.2
Ault described an approach to training inexperienced practitioners that
used tissue models for practice, the use of ultrasound devices, a focus on
use of large drapes and improved sharps handling that resulted in improved
accuracy and safety of CVC insertion.3 Ayas et. al. refer to the use of
ultrasound guidance to assist in CVC placement as being sporadic in their
study settings, which could contribute to the trends they are identifying,
however the evidence to support the routine use of such devices is to date
not strong.4
The only training method referred to by Ayas et. al. is supervision by
more experienced practitioners in the clinical field. Perhaps they could
consider introducing more formalized training, as described above, to
reduce the incidence of pneumothorax and other complications related to
CVC insertion for their patients. The routine data they are currently
collecting could assist in assessing the efficacy of such an approach.
Ros MacLeod, BN, Grad Cert CCN, Grad Dip Nursing, Nurse Unit Manager, ICU,
Western Health, Footscray, Australia, Ros.MacLeod@wh.org.au
References:
1. O’Grady, N. P., Alexander, M., Dellinger, E. P., Gerberding, J.L.,
Heard, S. O., Maki, D. G., Maur, H., McCormick, R. D., Mermel. L.A.,
Person, M. L., Raad, I. I., Randolph, A., Weinstein., R. A.. Guidelines
for the Prevention of Intravascular Catheter-Related Infections. National
Center for Infectious Diseases. 2002.
www.cdc.gov/mmwr/preview/mmwrhtml/rr5110al.htm
2. Sherertz, R. J., Ely, E., Wesley M. D., Westbrook, D. M., RN, Gledhill,
K. S., Streed, S. A., Kiger, B., Flynn, L., Hayes, S., Strong, S., Cruz,
J., Bowton, D. L., Hulgan, T. & Haponik, E. Education of Physicians-in
-Training Can Decrease the Risk for Vascular Catheter Infection. Annals of
Internal Medicine: 2000: 132(8): 641-648.
3. Ault, M. J. The Use of Tissue Models for Vascular Access Training:
Phase 1 of the Procedural Safety Initiative. Academic Emergency Medicine.
2007: 14(1):13.
4. Stone, M.B. Identification and correction guide wire malposition during
internal jugular cannulation with ultrasound. Journal of the Canadian
Association of Emergency Physicians. 2007:p(2):131.
It has been well recognized internationally that hospitals are not as
safe as they should be. In order to redress this situation, health care
services around the world have turned their attention to strategically
implementing robust patient safety and quality care program to identify
circumstances that put patients at risk of harm and then acting to prevent
or control those risks
In my hospital the patient safety program h...
It has been well recognized internationally that hospitals are not as
safe as they should be. In order to redress this situation, health care
services around the world have turned their attention to strategically
implementing robust patient safety and quality care program to identify
circumstances that put patients at risk of harm and then acting to prevent
or control those risks
In my hospital the patient safety program has been implemented for 10
months. During the implementation period, the team continuously
encouraging all the staffs for actively reporting. The self assessment
result for patient safety activities was 77% (using hospital accreditation
criteria). The team has 2 weekly meeting agenda for discussing and
reviewing the incident reporting.
During theses 10 months, the team has received 45 cases of incident
reporting. The members of team actively collect the data by interviewing
the medical staffs from various facilities.
Most of the cases are in category of “near miss”, and “adverse events”.
The data showed that most of the incident are related to drug/ blood
products and medical equipment. Root cause analysis of several cases
showed that inadequate communication and inappropriate team working are
the main causes of the incident.
The effort for promoting patient safety and reducing error
The team and hospital leader continuously encouraging the medical staffs
for incident reporting.
The interesting finding is 29% of the incident reporting come from the
patients and family.
The article from Dr. Wasson, et.al. is very interesting. The use of
information technology will make the reporting system easier, faster, and
enabling of early identification. The online system can sure that the
system will be working in 24 hours a day. Appropriate action can be taken
for preventing further injury. The other important thing is to educate the
patients and family for identifying the adverse events, and report the
adverse events immediately.
Recently Neuhauser and Dias raised an important question [1]: are
randomised clinical trials (RCT) necessary in quality improvement?
They conclude that “RCTs need to be embedded in generalized
replicatable theory. Otherwise it is a scientific house without
foundation” and argue that RCTs comparing drugs cannot be replicated for
two reasons: (1) after a decade or two the control arm has changed and (2)
replicati...
Recently Neuhauser and Dias raised an important question [1]: are
randomised clinical trials (RCT) necessary in quality improvement?
They conclude that “RCTs need to be embedded in generalized
replicatable theory. Otherwise it is a scientific house without
foundation” and argue that RCTs comparing drugs cannot be replicated for
two reasons: (1) after a decade or two the control arm has changed and (2)
replication may be considered unethical if the original trial showed a
difference. Thus it is tempting to draw the conclusion that the authors
suggest that RCT should not be used when the effect of a new drug is to be
tested.
Why is it so important that an experiment can be replicated? Say drug
B is shown to be superior to drug A, and later drug C is shown to be
superior to drug B. Then, who really cares whether the experiment
comparing drug A and B can be replicated or not?
The authors’ claim that RCTs cannot be replicated may be challenged.
If the conditions for the control arm has changed then the intervention
arm conditions are likely to have changed in parallel over time. Then we
expect to be able to replicate the findings. But we have no way of knowing
this. In fact, given that the same drug is used over the years, it is
unethical not to replicate the experiments regularly, according to
paragraph 6 in the introduction to the Helsinki Declaration
(www.wma.net/e/policy/b3.htm).
We agree with the authors that statistical process control (SPC) has
an important role to play in medicine [2]. But we feel that the use of SPC
for the comparison of drugs is quite risky due to the potential for the
introduction of all kinds of bias [2,3]. Another reason why SPC may be
inferior to RCTs is that the application of SPC requires the processes
studied to be brought in statistical control prior to the intervention
[2]. This may not be possible to achieve because the patient mix may vary
over time. It may be argued, then, that statistical risk adjustment may
take care of this problem. However, it is well known that this approach is
fraud with problems [2,3]. By contrast, the attainment of statistical
control is not an issue in the case of RCTs, precisely due to the random
assignment of patients to the intervention groups.
References
1. Neuhauser D, Dias M. Quality improvement research: are randomized
trials necessary? Qual Saf Health Care 2007; 16:77-80.
2. Winkel P, Zhang NF. Statistical Development of Quality in Medicine.
John Wiley and Sons Inc, 2007; 1 – 263.
3. Deeks JJ, Dinnes J, D’Amico R, Sowdon AJ, Sakarovitch C, Song F,
Petticrew M, Altman DG. Evaluating non-randomised intervention studies.
Health Technol Assess 2003;7:1-173.
We thank Dr. McCarthy for his thoughtful insights on the application
of situational awareness (SA) in medicine. We agree that physicians begin
with a limited amount of SA and often fail to maximize their SA using a
team approach. Because of the increasing complexity and acuity of care in
the outpatient setting, the risk of outpatient medical errors has
increased during the past several years.[1] Thus, t...
We thank Dr. McCarthy for his thoughtful insights on the application
of situational awareness (SA) in medicine. We agree that physicians begin
with a limited amount of SA and often fail to maximize their SA using a
team approach. Because of the increasing complexity and acuity of care in
the outpatient setting, the risk of outpatient medical errors has
increased during the past several years.[1] Thus, the use of SA in
outpatient care has become more critical than ever. Although physicians
function at times with a high degree of SA, they seldom continue to be
"aggressively skeptic" in the environment of outpatient care due to
factors such as fragmented communication, as Dr. McCarthy noted. In our
article we propose that achieving "team SA" could overcome some of these
obstacles. Team SA can act as a safety net for primary care physicians
"flying solo" and can be facilitated by a culture change in physician-physician communication.
We do acknowledge omission of a post-event debriefing in our
discussion. Nevertheless, we believe learning resulted from this case to
some extent. We discussed the case in detail at a traditional M&M
conference and communicated several lessons to the audience.
Unfortunately, as many physicians would agree, the quest to make systems improvements and policy changes based on isolated "stories" is not always successful.[2] Unlike aviation, medicine seeks evidence from randomized
controlled trials and other evidence-based literature to change health
care systems. With decreasing funding opportunities to support research
on medical error management, we hope that cases such as ours illustrate
the learning opportunities from other high-risk industries.
Hardeep Singh, MD MPH,
Laura A. Petersen, MD MPH,
Eric J. Thomas, MD MPH
No competing interests
References
(1) Phillips RL Jr, Bartholomew LA, Dovey SM, Fryer GE Jr, Miyoshi
TJ, Green LA. Learning from malpractice claims about negligent, adverse
events in primary care in the United States. Qual Saf Health Care 2004;
13(2):121-126.
(2) Steiner JF. The Use of Stories in Clinical Research and Health
Policy. JAMA 2005; 294(22):2901-2904.
As a retired USAF pilot-physician, I commend Singh et al. for their
excellent use of aviation Situational Awareness as an analysis tool. I
wish only to add a subtle dimension to their illustration of situational
awareness:
"LSA" - loss of situational awareness – began as a universally recognized
NATO acronym. But…one can not lose what one never had.
SA in military and air carrier aviation universally b...
As a retired USAF pilot-physician, I commend Singh et al. for their
excellent use of aviation Situational Awareness as an analysis tool. I
wish only to add a subtle dimension to their illustration of situational
awareness:
"LSA" - loss of situational awareness – began as a universally recognized
NATO acronym. But…one can not lose what one never had.
SA in military and air carrier aviation universally begins at a maximum,
and may deteriorate backwards from Level 3 of Endsley’s model. Maximal SA
at the outset of a mission is achieved by all team members studying all
environmental factors that might affect the outcome; mentally rehearsing
the mission timeline, actions, and threats; and planning for contingencies
during the preflight briefing. The team begins with a high level, mental
model of what is to come.
Sadly, pre-event reviews are vanishingly rare in medicine, and physicians
begin with very limited, or absent SA, as illustrated by the outpatient
case in the paper. Further, SA in outpatient medicine, if it exists at
all, is compromised by the fragmentation and time displacement of cues and
communications. Ironically, is easier to discern SA, good and bad, in the
confines of the high risk areas of inpatient care: the OR, Labor and
Delivery, and ED.
Medical team training courses emphasize the value of briefings in setting
the stage for good SA, and train high risk team leaders to conduct them.
Thus far team training is not widely deployed or accepted. Nor are
briefings cited in such patient safety resources as the AHRQ Web M&M.1
Another fundamental, but subtle, difference between aviation and medicine
is decision making. The hapless primary care physician was "flying solo"
and making independent judgments. Despite the Hollywood images, fighter
pilots rarely make solo decisions. Flying in multiples for "mutual
support," air combat teams operate with strong, visible, designated
leadership, but simultaneously practice collaborative, consensus decision
making. Similarly, "cockpit resource management," the progenitor of
medical team training, reversed decades of left-seat, hierarchical,
autocratic decisions that placed passengers at the same risk level as the
described patient in favor of collaborative decision making after inputs
by all, even passengers.2
Lastly, the authors omit any discussion of a post-event debriefing of this
adverse outcome. Thus, learning was not captured, nor system improvements
made. Debriefings – as short as 30s or lasting for hours – are mandatory
in aviation and result in real-time, actual, lasting CQI. Early efforts
to use traditional M&M conferences offer some promise in debriefings.3
Medicine has much to adopt and adapt from other high risk professions,
aviation, nuclear power, and even mining. The authors have advanced that
journey significantly.
In his review of our paper on pro-anorexia Internet communities
(Quality and Safety in Health Care 2006;15:220-222), Dr Smith introduced
one inaccuracy into an otherwise concise summary. He mistakenly
attributed a quotation from a participant in the Internet forum to our
researcher. Angela (a pseudonym) had commented that she was intending to
leave the group because she did not approve of some of t...
In his review of our paper on pro-anorexia Internet communities
(Quality and Safety in Health Care 2006;15:220-222), Dr Smith introduced
one inaccuracy into an otherwise concise summary. He mistakenly
attributed a quotation from a participant in the Internet forum to our
researcher. Angela (a pseudonym) had commented that she was intending to
leave the group because she did not approve of some of the comments made
by other participants. Dr Smith put these words in the mouth of our own
Dr Ward, and then wondered why she had decided to stop her research.
This interpretation gives a slightly misleading overall impression of
our own response to the pro-anorexia community. Whatever our own feelings
about the philosophy of the group, our analysis sought to provide as
objective an understanding of the participants' views as possible. We
concluded our paper by suggesting that there is a coherent model of
anorexia behind the pro-anorexia movement, and that to comprehend this
apparently irrational desire to sustain very low body weight, it is
necessary to understand this model first.
We hope this clarification will assist readers to make sense of our
research and perhaps to take a look at the original paper. (Fox N, Ward K,
O’Rourke A. Pro-anorexia, weight-loss drugs and the internet: an 'anti-
recovery' explanatory model of anorexia. Sociol Health Illness
2005:944–71.)
According to MM Bismark et Al (1) complaints that are brought to a
Commissioner in NZ offer a potentially valuable “window” on serious
threats to patient safety. In Italy, the consultative and conciliatory
commissions (“Commissioni miste conciliative”) and the ombudsmen (second
level organisations) supply unsatisfactory results or are not even
established (2). Furthermore, epidemiological data lik...
According to MM Bismark et Al (1) complaints that are brought to a
Commissioner in NZ offer a potentially valuable “window” on serious
threats to patient safety. In Italy, the consultative and conciliatory
commissions (“Commissioni miste conciliative”) and the ombudsmen (second
level organisations) supply unsatisfactory results or are not even
established (2). Furthermore, epidemiological data like those of the NZQHS
are very scarce. We had only a possibility in this field: to carry out a
survey to explore if an independent patient’s agency could facilitate
local learning and action to improve the quality of health services.
Two hundred forty complaints and accounts of presumed untoward events
presented by people to our voluntary Patients Agency in Milan
(Cittadinanzattiva) were analysed. Every complaint enclosed one or more
clinical records. Our aim was to compare allegations contained in the
written complaints and the results of a retrospective case records review.
An expert physician examined all the clinical records produced and
identified when an “avoidable adverse event” was present (3). A
medicolegal expert independently reviewed 89 complaints.
According to the patients the cause of the complaint was: *A delay in
diagnosis and treatment (89 cases). *The failure or a complication in the
technical performance of an indicated operation (82 cases), or of an
indicated invasive procedure (24 cases ). *Lack of care or attention,
failure to attend, lack in monitoring of a patient (19 cases). *Delay or
failure in treatment (9 cases). *Others (9 cases).
In the physician record review, 87 out of 240 complaints were associated
with a preventable adverse event (mainly occurring in hospital); 22 were
serious and preventable, 12 of them from a failure or a complication of an
indicated operation.
We know that there are a number of potential shortcomings in our study.
Nevertheless, the survey confirm what kind of useful information about
substandard medical care we can gather also from this type of
documentation. With no patient lawyer or representative (4) present in the
hospital, and with claim management firmly controlled by the medical
experts, who wishes to complain will be more motivated if the management
of the claims was supported by an independent Agency to ensure objectivity
before the disputes, taking on responsibility for reporting the incident
to the interested organization and for feed-back to the citizen.
But, in my opinion, the Italian voluntary Patients Agencies have a very
weak voice.
Roberto Natangelo
Retired Physician
Cittadinanzattiva (Active Citizenship. Via Mecenate n. 25. 20138 Milan. Italy)
e-mail: roberto.natangelo @ libero.it
References
1. – Bismark MM, Brennan TA, Paterson RJ, Davis PB, Studdert DM.
Relationship between complaints and quality of care in New Zealand: a
descriptive analysis of complainants and non-complainants following
adverse events. Qual Saf Health Care 2006;15:17-22.
2. – Convegno: “La comunicazione pubblica in sanità” (Meeting: Public
communication in health service) Associazione Stampa Medica Italiana. Atti
interventi. Roma 6-10 maggio 2002.
3. - Wilson RM , Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton
JD. The quality in Australian Health Care Study. Med J Aust 1995;153:458-
471.
4. - Entwistle VA, Andrew JE, Emslie MJ, Walker KA, Dorrian C, Angus VC,
Conniff AO. Public opinion on systems for feeding back views to the
National Health Service. Qual Saf Health Care 2003;12:435-442.
It was a great pleasure to read the article by F. Davidoff and P.
Batalden published in October 2005 issue of the journal Quality and Safety
in Health Care, pages 807–814. The article clearly pictures how failing
to publish quality improvement (QI) may have several adverse implications
hindering the overall medical quality improvement expected by consumers,
accrediting agencies, federal agencies and...
It was a great pleasure to read the article by F. Davidoff and P.
Batalden published in October 2005 issue of the journal Quality and Safety
in Health Care, pages 807–814. The article clearly pictures how failing
to publish quality improvement (QI) may have several adverse implications
hindering the overall medical quality improvement expected by consumers,
accrediting agencies, federal agencies and other governmental bodies.
Lack of compensation (Staker, 2003) and forbidding clinician from
publishing results may not help them to apply quality improvement (QI)
methodologies to continuously improve care as many academic institutions
evaluate their performance based on publication which is quite obvious in
research. QI studies typically consist of a series of small,
interrelated, stepwise experiments allowing new knowledge at each step to
be assimilated into the next step, and allowing “mid-course” corrections
in the study if necessary. In contrast, clinical trials are typically
large long term studies with new knowledge only coming at the end although
monitored regularly to stop when an overwhelming benefit or harm found.
By encouraging publication of good quality improvement initiatives
and publication of such activities will benefit 1) the health care
operations to provide better care, and 2) bring reformation in reporting
research evidence. QI evidence-based management initiatives will enhance
the level of reading, understanding and integrating research evidence
which in turn will increase the demands for manuscripts to report
scientific evidence transparently. Basing clinical trial results,
Rembold, (1998) reported that to prevent a breast cancer death in 9 years
the number needed to treat was 695 for women aged 60-69 where as it was
4576 for women aged 40-49. When patients are advised to go for
preventative treatments clinicians providing such specific information
will bring a better informed decision making for the overall society.
Both QI and research are like two sides of the same coin and play a
vital role in healthcare. “Generalizable knowledge” plays a key role in
distinguishing between QI and clinical trials. However, not all clinical
trials yield generalizable knowledge but some QI can indeed yield
generalizable knowledge. Shewhart’s (1932) and Deming’s (1986) cycle of
learning and improvement came from QI and is applicable to any QI study.
Juran’s (1998) “Diagnostic Journey,” “Remedial Journey,” and “Hold the
Gains” likewise have universal applicability ranging from large industrial
companies to service-based enterprises including healthcare organizations.
In spite of Title 45 CFR Part 46, Section 46.101(b) which clearly states
that QI studies would be exempt from the IRB process, recognizing the
importance of QI to improve healthcare, institutions trying to make an
oversight process for difficult to distinguish projects is laudable (Kofke
& Rie, 2003). Similarly, Baily (2005) recommended specialized QI IRB
along with some administrative process to oversee QI projects.
Setting up a registration and review process in order to improve
publication standards for QI projects may also benefit in preventing most
of the misunderstandings and misuse (Johnson, 2004; Grossberg, 2004) when
new improvement ideas are brought forth. This will also increase number of
meaningful projects and publications which in turn help create a QI
culture inbuilt in their daily work processes as research. Publication of
QI efforts will establish QI value for healthcare quality and therefore
will increase potential to receive grants from granting agencies as both
QI and research are essential societal goals.
References
1. Baily M. The ethics of improving health care quality and safety: A
hastings center report. The University of Texas M. D. Anderson Cancer
Center, Oct 4th 2005.
2. Davidoff F and Batalden P. Toward stronger evidence on quality
improvement. Draft publication guidelines: the beginning of a consensus
project. Qual Saf Health Care 2005; 14: 319-325.
3. Staker LV. Teaching performance improvement: an opportunity for
continuing medical education. J Contin Educ Health Prof. 2003 Spring;23
Suppl 1:S34-52. \
4. Grossberg M. Plagiarism and Professional Ethics—A Journal Editor's
View, The Journal of American History, 2004;90(4):1333.
5. Johnson SH. Who's idea is it?. Nurse Author Ed. 2004 Spring;14(2):1-4.
6. Rembold CM. Number needed to screen: development of a statistic for
disease screening. BMJ. 1998 Aug 1;317(7154):307-12.
7. Shewhart WA. Statistical Method From the Viewpoint of Quality Control,
the Department of Agriculture, 1939.
8. Deming WE. (1986). Out of the Crisis. Cambridge, MA: Massachusetts
Institute ofbTechnology, Center for Advanced Engineering Study
9. Joseph M. Juran and A. Blanton Godfrey, Juran’s Quality Handbook,
McGraw-Hill, 1998.
10. Kofke WA & Rie MA. Research ethics and law of healthcare system
quality improvement: The conflict of cost containment and quality.
Critical Care Medicine. 31(3) Supplement:S143-S152, March 2003.
In their recent study, Shojana et al highlight the importance of
necropsy to clinical care by demonstrating how diagnostic sensitivity for
three conditions is overestimated without necropsy results.[1] This study
prompted an editorial by Guly calling for more research to demonstrate
that increasing necropsy rates can improve patient care.[2]
Clearly, the evidence establishing the value of necr...
In their recent study, Shojana et al highlight the importance of
necropsy to clinical care by demonstrating how diagnostic sensitivity for
three conditions is overestimated without necropsy results.[1] This study
prompted an editorial by Guly calling for more research to demonstrate
that increasing necropsy rates can improve patient care.[2]
Clearly, the evidence establishing the value of necropsy for
identifying diagnostic and management issues relevant to patient care[3] is
not preventing the international decline in the number of hospital
necropsies. Thus, we support Guly’s petition for more evidence and
describe our efforts to improve communication between pathologists and
clinicians to facilitate such research.
At the Victorian Institute of Forensic Medicine, forensic necropsies
are conducted on approximately 80% of hospital deaths investigated by the
Coroner’s Office in Victoria, Australia.[4] A significant barrier to using
the lessons of forensic necropsy for the improvement of clinical care is
the lack of communication channels between Coroners and clinicians. The
Clinical Liaison Service, which is the medical investigation unit
assisting the State Coroners Office in Victoria, attempts to bridge the
gap between Coroners and clinicians.
Established in 2002, the Clinical Liaison Service reviews the
hospital care of the deaths reported to the Coroner. This unit developed
a standardized review process that integrates the necropsy results with
the review of medical records to identify potential system failures in
clinical practice. The review process includes a multi-disciplinary
discussion with a Coroner, forensic pathologist, clinicians and coronial
staff to determine which issues, if any, should be investigated further
for the goal of system improvement and death prevention. Approximately
2,000 hospital deaths have been reviewed by the Clinical Liaison Service
and twenty-five percent of these have undergone review at the multi-
disciplinary discussion.
At the conclusion of the investigation the Coroner makes a formal
legal finding, that includes the issues of concern and recommendations to
improve healthcare practice. As the Coroner’s recommendations are not
always widely distributed,[5] the Clinical Liaison Service provides feedback
to hospital staff to improve health professionals understanding of cases
with patient safety implications. This feedback includes face to face
presentations and a synopsis of noteworthy cases in the unit’s quarterly
publication the Coronial Communiqué.[6]
As the work by Shojana et al. shows, necropsy results have the
capacity to impact clinical practice far more broadly than at the
individual case level alone. In Victoria, a national database, the
National Coroners Information System (NCIS), has been established to
provide a national repository of information about each Coroner’s case,
including the forensic necropsy report.
It is vital that health researchers and clinicians consider the
lessons from necropsy results in individual cases as well as in an
aggregated form. Furthermore, their resulting information must be
communicated widely or many valuable lessons may be overlooked.
References
1. Shojania KG, Burton EC, McDonald KM, et al.Overestimation of
clinical diagnostic performance rates caused by low necropsy rates. Qual
Saf Health Care 2005;14:408–13.
2. Guly H. More necropsies will improve patient care: has the case
been made? Qual Saf Health Care. 2005 Dec;14(6):397.
3. Darok M, Gatternig R, Mannweiler S. Late complications after
medical treatment--malpractice or fate?
Med Law. 2004;23(3):489-94.
4. Emmett SL, Ibrahim JE, Charles A, Ranson DL. Coronial autopsies:
a rising tide of objections.
Med J Aust. 2004 Aug 2;181(3):173.
5. Bugeja L, Ranson D. Coroners' recommendations: a lost
opportunity. J Law Med. 2005 Nov;13(2):173-5.
I congratulate the authors on this excellent series.
Some authors (for example[1,2]), regard active vomiting as a contraindication to cricoid pressure because of reported cases of oesaphageal rupture, and cadaveric experiments. This current paper, however, makes no mention of vomiting as a contraindication.
I would appreciate knowing whether authors reject this contrandication and bel...
I congratulate the authors on this excellent series.
Some authors (for example[1,2]), regard active vomiting as a contraindication to cricoid pressure because of reported cases of oesaphageal rupture, and cadaveric experiments. This current paper, however, makes no mention of vomiting as a contraindication.
I would appreciate knowing whether authors reject this contrandication and believe the benefits of cricoid pressure outweigh the risks.
Regards,
Erich Schulz
References
1. Landsman I. "Cricoid pressure: indications and complications."
Paediatr Anaesth. 2004 Jan;14(1):43-7.
2. Allman KG, Wilson IH. "Oxford Handbook of Anaesthesia", OUP, 2001,
p846.
Most Intensive Care Units (ICU) collect comprehensive data relating to patient demographics, diagnoses and complications and some use this information to benchmark and guide quality improvement activities aimed at improving patient outcomes and reducing iatrogenic complications. Ayas et. al. are to be commended for using routine information they collect in an attempt to identify trends and possible contributing factors t...
It has been well recognized internationally that hospitals are not as safe as they should be. In order to redress this situation, health care services around the world have turned their attention to strategically implementing robust patient safety and quality care program to identify circumstances that put patients at risk of harm and then acting to prevent or control those risks In my hospital the patient safety program h...
Recently Neuhauser and Dias raised an important question [1]: are randomised clinical trials (RCT) necessary in quality improvement?
They conclude that “RCTs need to be embedded in generalized replicatable theory. Otherwise it is a scientific house without foundation” and argue that RCTs comparing drugs cannot be replicated for two reasons: (1) after a decade or two the control arm has changed and (2) replicati...
Dear Editor,
We thank Dr. McCarthy for his thoughtful insights on the application of situational awareness (SA) in medicine. We agree that physicians begin with a limited amount of SA and often fail to maximize their SA using a team approach. Because of the increasing complexity and acuity of care in the outpatient setting, the risk of outpatient medical errors has increased during the past several years.[1] Thus, t...
Dear Editor,
As a retired USAF pilot-physician, I commend Singh et al. for their excellent use of aviation Situational Awareness as an analysis tool. I wish only to add a subtle dimension to their illustration of situational awareness: "LSA" - loss of situational awareness – began as a universally recognized NATO acronym. But…one can not lose what one never had. SA in military and air carrier aviation universally b...
Dear Editor,
In his review of our paper on pro-anorexia Internet communities (Quality and Safety in Health Care 2006;15:220-222), Dr Smith introduced one inaccuracy into an otherwise concise summary. He mistakenly attributed a quotation from a participant in the Internet forum to our researcher. Angela (a pseudonym) had commented that she was intending to leave the group because she did not approve of some of t...
Dear Editor,
According to MM Bismark et Al (1) complaints that are brought to a Commissioner in NZ offer a potentially valuable “window” on serious threats to patient safety. In Italy, the consultative and conciliatory commissions (“Commissioni miste conciliative”) and the ombudsmen (second level organisations) supply unsatisfactory results or are not even established (2). Furthermore, epidemiological data lik...
Dear Editor,
It was a great pleasure to read the article by F. Davidoff and P. Batalden published in October 2005 issue of the journal Quality and Safety in Health Care, pages 807–814. The article clearly pictures how failing to publish quality improvement (QI) may have several adverse implications hindering the overall medical quality improvement expected by consumers, accrediting agencies, federal agencies and...
Dear Editor,
In their recent study, Shojana et al highlight the importance of necropsy to clinical care by demonstrating how diagnostic sensitivity for three conditions is overestimated without necropsy results.[1] This study prompted an editorial by Guly calling for more research to demonstrate that increasing necropsy rates can improve patient care.[2]
Clearly, the evidence establishing the value of necr...
Dear Editor,
I congratulate the authors on this excellent series.
Some authors (for example[1,2]), regard active vomiting as a contraindication to cricoid pressure because of reported cases of oesaphageal rupture, and cadaveric experiments. This current paper, however, makes no mention of vomiting as a contraindication.
I would appreciate knowing whether authors reject this contrandication and bel...
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