One example of our almost universal, daily inflicting of emotional
harm on patients is our mis-labeling of the patient's presenting problem
as the 'Chief Complaint'.
Years ago, an ICU patient said plaintively, "I'm not a complainer."
after a bedside presentation is which that is just what he was called.
Let's call it the 'Presenting Problem'--in our talk and in our notes.
It might contribute to a clima...
One example of our almost universal, daily inflicting of emotional
harm on patients is our mis-labeling of the patient's presenting problem
as the 'Chief Complaint'.
Years ago, an ICU patient said plaintively, "I'm not a complainer."
after a bedside presentation is which that is just what he was called.
Let's call it the 'Presenting Problem'--in our talk and in our notes.
It might contribute to a climate in which extreme cases become more rare.
And perhaps we could eliminate these into the bargain:
"The patient has failed multiple therapies." (when it is the therapies
that failed)
"The patient is a poor historian." (when the physician is meant to be the
historian)
"The patient admits/denies. . . "
Marshall et al's (2014) paper was highlighted as an exemplar of
stakeholder participation by a speaker at a recent public health research
conference, held in Newcastle. Participants gave useful feedback about
many of the core issues raised, which we reflect here.
Marshal et al's (2014) 'Researcher in Residence' models are suggested
as a means of co-engaging academics and practitioners in the promotion of
evide...
Marshall et al's (2014) paper was highlighted as an exemplar of
stakeholder participation by a speaker at a recent public health research
conference, held in Newcastle. Participants gave useful feedback about
many of the core issues raised, which we reflect here.
Marshal et al's (2014) 'Researcher in Residence' models are suggested
as a means of co-engaging academics and practitioners in the promotion of
evidence-informed service improvement. But participants at our event
raised questions about public involvement as key stakeholders from earlier
on in the research process. In the experience of our presenters and
participants, research that starts from questions derived from both
academics and participants (i.e. that is co-produced) is more likely to
address patient needs than questions driven by academics, funders or
institutions.
Important (though hardly novel) questions remain. Are academics open
enough to co-produced research ideas? Is there sufficient willingness to
see questions differently, to work differently, and to enable tacit
knowledge and patient and public experience to be valued as a legitimate
contribution to the research process? Public stakeholders at our event
expressed hunger to know how to engage with academia, but felt the
opportunities to do so were unclear. There is much to learn from Patient
and Public Involvement (PPI) in research.
As others have observed, effective patient and public involvement
(PPI) requires difficult conversations about vested interests (Greenhalgh
et al 2014) and power and status among stakeholders (Centre for Social
Justice 2012). Discussions about paying research participants can present
thorny issues for some, among wider concerns around how public views are
sought/used/valued/acknowledged. PPI raises philosophical questions
around 'independent research' and what this means, as well as similarly
tricky issues around what expertise and experience 'counts' (for
researchers and the public) and how to address institutional barriers and
facilitators to its use.
Public health, classically defined as 'organised community effort' to
prevent disease, prolong life and promote health (Winslow 1920 cited in
Lang and Raynor BMJ 2012), presents a unique set of challenges. The
relocation of public health responsibilities to local government raises
questions about the different cultures of research and evidence use, the
place of public involvement and democratic accountability, and how to use
opportunities to address the social determinants of health. The exemplars
used by Marshall et al (2014) are all drawn from clinical settings, and
models of PPI may need adapting for use in public health.
Our event showcased pockets of good practice and highlighted
different methods to involve patients and the public, including in public
health (see www.fuse.ac.uk). Some of these have been published elsewhere
(Centre for Social Justice 2012, Lewis and Russell 2014). Taken together
with feedback from those with experience of PPI, we can discern some
underlying principles to guide meaningful PPI in research (which may also
support research use in practice). Though not comprehensive, these include
the need to; clarify motives; reach out to marginalised groups; use
existing networks; take account of context; be reflexive and adaptive;
value different forms of knowledge and expertise; be committed to the
possibilities of facilitating change.
Neither in public health nor clinical settings have we 'cracked it'
in terms of PPI. Our conference opened a black box of similarities and
contrasts between PPI in public health and clinical settings - requiring
different approaches. Learning opportunities can flow in both directions,
recognising the complexity inherent in PPI in population health
interventions (Best et al 2009).
The researcher in residence model introduced by Marshall et al (2014)
is one approach to co-production. However, we argue that early
involvement in setting research agendas is more likely to meet the needs
of the public. There are critical blocks to effective engagement, for
example silo thinking, the "paradigm shift" (Hunter 2009) required in
academia, and specific skills amongst researchers. New ways of doing
research must have co-production at their core - they must be
collaborative and engage stakeholders from the start of the research
process, when questions are being formulated, through to dissemination.
References
Best, A., Terpstra, J.L., Moor, G. Riley, B., Norman, C.D., Glasgow, R.E.
(2009) Building knowledge integration systems for evidence-informed
decisions Journal of Health Organization and Management, Vol. 23, issue 6,
pp 627 - 641.
Centre for Social Justice and Community Action, Durham University and
the National Co-ordinating Centre for Public Engagement (2012) Community-
based participatory research. A guide to ethical principles and practice,
available from www.publicengagement.ac.uk
Hunter, D. J. (2009) Leading for Health and Wellbeing: the need for a
new paradigm Journal of Public Health, Volume 31, No. 2, pp 202-204
Lang, T and Raynor, G (2012) Ecological public health: the 21st
century's big idea? British Medical Journal 345: e5466. 21 August.
Lewis and Russell (2011) Being embedded: A way forward for
ethnographic research Ethnography 2011 12: 398. DOI:
10.1177/1466138110393786
Lomas, J (2007) the in-between world of knowledge brokering British
Medical Journal, 334, (7585): 129.
Conflict of Interest:
All authors were members of the organising committee for Beyond tokenism: PPI with impact
Enriching patient and public involvement in public health research, October 16th 2014. The event was sponsored by the Newcastle Institute of Social Renewal, Newcastle University Faculty of Medical Science, Fuse Centre for Translational Research in Public Health and Involve North East.
We read with interest your Editorial re the role of families in
preventing avoidable harm in children (1).
Many public hospitals in Queensland Health in Australia have now
implemented Ryan's Rule. When Ryan's parents were worried he was getting
worse they didn't feel their concerns were acted upon in time. It was
subsequently established that Ryan died from likely preventable causes.
Ry...
We read with interest your Editorial re the role of families in
preventing avoidable harm in children (1).
Many public hospitals in Queensland Health in Australia have now
implemented Ryan's Rule. When Ryan's parents were worried he was getting
worse they didn't feel their concerns were acted upon in time. It was
subsequently established that Ryan died from likely preventable causes.
Ryan's Rule was developed to provide patients of any age, families and
carers with another way to get help. Families and carers are educated by
staff and with the prominent display in the wards of Ryan's Rule posters
containing the following advice re escalation.
There are three steps for families and carers to raise their
concerns:
[1] talk to a nurse or doctor about your concerns. If you are not
satisfied with the response->
[2] Talk to the nurse in charge of the shift. If you are not
satisfied with the response ->
[3] Phone 13 Health (13 43 25 84) or ask a nurse to call on your
behalf. Request a Ryan's Rule Clinical Review and provide information
about hospital name, patient's name. ward, bed number, your conduct
number.
A Ryan's Rule nurse or doctor will review the patient and assist.
We await with interest the results of the prospective audit of this
statewide process.
Yours sincerely,
Dr Mai-Ing Koh MBBS (JCU), Resident, Namboru Hospital
Assoc Prof Tieh Hee Hai Guan Koh BA MA (Oxon) MBBChir(Cantab) MD
(Cantab) FRCPCJ
Director Neonatology The Townsville Hospital
Queensland 4814
AUSTRALIA
1) Roland, D. But I told you she was ill! The role of families in
preventing avoidable harm in children
BMJ Qual. Saf. 2015 24:186-187
We thank Dr. Iedema for highlighting that a gap exists in providers
having the skillset to 'work smarter.' We agree that novel approaches to
healthcare improvement are required that move beyond gadget-based
solutions and that require a new set of skills of providers and provider
organizations. The suggestion of video taping one's performance to review
how the system (and its participants) currently operates and reflect...
We thank Dr. Iedema for highlighting that a gap exists in providers
having the skillset to 'work smarter.' We agree that novel approaches to
healthcare improvement are required that move beyond gadget-based
solutions and that require a new set of skills of providers and provider
organizations. The suggestion of video taping one's performance to review
how the system (and its participants) currently operates and reflect on
how to (re-) design their workflows is intriguing. It exemplifies the
concept of 'exnovation' or 'innovation from within', meaning innovation
arises from within established practice, and from within practitioners.
However, our article did not aim to imply that it is providers who
are responsible for, or required to gain the skills to work smarter. Our
message is directed to all those seeking and driving healthcare system
improvement. Although we agree that providers may benefit from the
skillsets that Dr. Iedema proposed, we believe that those seeking change
also need additional skillsets and perspectives. We can no longer presume
that healthcare providers have the space to add new tasks, workflows,
procedures etc. We have, as a system, to work on simplifying the current
work environment, finding non-value added tasks and work with healthcare
providers to design ways of achieving improved outcomes that don't add net
new workload or complexity. Now some may argue that added work at one
part of the system may have larger benefits downstream. This may be true
but those charged with carrying the weight of the new tasks have to do so
in a sustainable and reliable way. Otherwise subsequent change
initiatives will disrupt this balance and its downstream benefits.
Our message was also aimed at those adding new regulation, policies,
performance measures and incentives or disincentives. Adding pressure on
top of an environment that doesn't have the space nor the knowledge and
skill to create it only adds to workplace burden, resistance and non-
sustained improvement. We believe that there needs to be a system-wide
look at the capabilities and investments required to create a 'working
smarter' healthcare system. Providers will play their role but they need
a commitment that a 'work harder' strategy is no longer acceptable.
The Hayes, Batalden and Goldmann piece is an important contribution
to the debate about what exactly is practice improvement. Most practice
improvement thinking is anchored in the 'innovation' paradigm, and this
paradigm is predominantly 'gadget thinking'. Others' solutions are to be
adopted here because they produce great outcomes elsewhere. Except now we
have to figure out how we can get the gadget to work.
Few commen...
The Hayes, Batalden and Goldmann piece is an important contribution
to the debate about what exactly is practice improvement. Most practice
improvement thinking is anchored in the 'innovation' paradigm, and this
paradigm is predominantly 'gadget thinking'. Others' solutions are to be
adopted here because they produce great outcomes elsewhere. Except now we
have to figure out how we can get the gadget to work.
Few commentators have been game to shift towards acknowledging that care
practices are now too complex for 'gadget thinking'. Hayes and colleagues
are an exception. They propose that frontline professionals themselves
need to become smarter at 'co-designing' solutions that suit their unique
contexts and practices. Here, we are not talking about adopting new
gadgets from elsewhere. We care talking about people who will - and who
have the skill to - take inspiration from the smartness that may be
invested in whatever gadget or improvement initiative, and apply this
smartness to their own workpractices. Indeed, these professionals may not
even need inspiration to come from elsewhere: they may well be motivated
by issues arising in their own work, and decide to redesign their
practices.
But to date, we have not focused on what this ability to co-design care
practices consists in. We expect frontline professionals to somehow know
how to co-design practice, and know how to be smart about what they do and
what they should do. And yet, their training has not skilled them in
practice design. We nevertheless expect them to readily (re)design the
organisational dimensions of their work. Usually, such designs fall prey
to people's espoused ideas and pre-existing assumptions about how things
work and should work. Often there are worrying gaps between what people
know and what they (think they) do. Put differently, smartness, in the
sense of learning about how to manage complex situations and improve
complex practices, is rare.
Smartness cannot be expected to exist or arise in situations where there
are no resources available for professionals to learn about (or 'make
explicit') the complexities of their own day-to-day work. Smartness must
be nurtured.
The way par excellence to achieve this is professionals, just as do top-
end athletes, studying their own performances. In sport, video-ing one's
game for transforming good performances into excellent ones is now not
just common but also indispensable. This is about capitalising on and
building on existing strengths. By analogy, video-ing in situ practice and
using the resulting footage to reflect on the work is central to enhancing
smartness at work. This is what Katherine Carroll and Jessica Mesman and
colleagues have referred to as 'exnovation'.
Of course, many excuses and objections are raised to auto-observation, the
most common ones of which are privacy, the Hawthorne effect, and
subpoenable evidence. But these concerns are over-stated, and they trade a
real need and opportunity for improvement and smartness off against
maintaining the status quo. Without auto-observation, existing habits and
routines will go on unquestioned. Work can only become harder, as the only
solutions to improvement will remain gadget-based. Smartness, by contrast,
starts from where we are, and explores where we can go.
Dear Sir,
It is with great interest that we read the recent publication by Thomas and colleagues investigating ward-based patient care.1 They describe a study in which 28 medical students were randomised to either control (no intervention) or intervention (performance feedback and error management training) groups, performing simulated ward rounds complicated by environmental distractors. Significant reductions in errors were se...
Dear Sir,
It is with great interest that we read the recent publication by Thomas and colleagues investigating ward-based patient care.1 They describe a study in which 28 medical students were randomised to either control (no intervention) or intervention (performance feedback and error management training) groups, performing simulated ward rounds complicated by environmental distractors. Significant reductions in errors were seen in both groups from the first to the second ward round, with a significantly greater reduction seen in the intervention group.
We thoroughly commend on their efforts to add to the body of literature for what is such a crucial, but until now has been a sparsely investigated, area of care. There can be no doubt that in current practice, the conduct of ward rounds may be hugely variable,2, 3 with significant implications for patient outcomes.2 In surgical literature, the phenomenon of "failure to rescue" describes failures in ward-based management of complications, which represent a major source of variability in surgical outcomes, emphasising the need to focus on ward rounds to improve outcomes.4
Future research in this area must be robust, evidence-based, and ideally tied to clinically relevant subjects and outcomes. With this in mind, we would like to raise several questions in reference to the study by Thomas et al. How were the "distractors" selected? Loud radio noises and upset relatives would appear to represent fairly arbitrary factors with unclear relevance to clinical care. Additionally, the authors appear to suggest that the intervention included very specific feedback on how to cope with these distractors - if part of the scoring is to assess whether the radio was turned off, and the intervention includes instruction to do so, can the result be truly deemed valid? Finally, was there a reason for selecting medical students rather than a more valid population of clinical staff such as house officers, or even residents, who are commonly responsible for the ward round?
Recently, we have described the Surgical Ward-care Assessment Tool (SWAT), a checklist-based tool for technical skills, and the Ward-based Non-Technical Skills score (W-NOTECHS), a Likert-based tool for non-technical skills; together these represent objective, validated scoring scales for ward round performance.5 It is possible that the adaptation of such surgical rating scales to address other specialty populations may present an effective way forward. We are fully in agreement with Thomas and colleagues in their statement that to move ward round initiatives forward, we must in future focus on changing patient safety behaviours. Thus, future assessments of ward round performance must focus on objective assessment metrics which are generalisable across studies, contexts, and specialties. Only in this manner can reliable, reproducible interventions be developed to standardise and improve care and outcomes.
References
1. Thomas I, Nicol L, Regan L, et al. Driven to distraction: a prospective controlled study of a simulated ward round experience to improve patient safety teaching for medical students. BMJ Qual Saf 2014.
2. Pucher PH, Aggarwal R, Darzi A. Surgical ward round quality and impact on variable patient outcomes. Ann Surg 2014; 259:222-6.
3. Blucher KM, Dal Pra SE, Hogan J, Wysocki AP. Ward safety checklist in the acute surgical unit. ANZ J Surg 2013.
4. Silber JH, Williams SV, Krakauer H, Schwartz JS. Hospital and patient characteristics associated with death after surgery. A study of adverse occurrence and failure to rescue. Med Care 1992; 30:615-29.
5. Pucher PH, Aggarwal R, Srisatkunam T, Darzi A. Validation of the Simulated Ward Environment for Assessment of Ward-Based Surgical Care. Ann Surg 2014; 259:215-21.
Conflict of Interest:
Rajesh Aggarwal is a consultant for Applied Medical. No other competing interests declared.
Recently, Provenzano and colleagues found that an electronic tool
collecting real-time clinical information directly from front-line
providers was both feasible and useful to evaluate inpatient deaths [1].
These findings concur with our evaluation of the preventability of death
using a simple electronic evaluation tool in our 46-bed adult Intensive
Care Unit.
Recently, Provenzano and colleagues found that an electronic tool
collecting real-time clinical information directly from front-line
providers was both feasible and useful to evaluate inpatient deaths [1].
These findings concur with our evaluation of the preventability of death
using a simple electronic evaluation tool in our 46-bed adult Intensive
Care Unit.
From September 2010 to September 2011 an email was send to the
attending intensivist each time a patient died in our intensive care
including 2 questions: "Was this death preventable? If yes, what was the
cause of preventability?". The definition of preventable mortality was
provided using three criteria: the illness was survivable, care was
suboptimal, and suboptimal care was related to death. No reminding emails
were sent. In addition, the patient charts of all cases were
retrospectively reviewed by two ICU nurses and a physician.
A total of 306 patients (9.9%) died. APACHE IV Standardised Mortality
Rate was 0.77. In 48 of these deceased patients the APACHE IV based
mortality risk was below 20%. Response rate was 92% and 47 deaths (15%)
were reported to be potentially preventable. Large inter-individual
variations between the intensivists (n=24) were observed. Response varied
between 65% and 100% and preventable death judgments varied from none to
66%. When using blinded chart review was by the nurses and physician
judged death potentially preventable in 7%, 11%, and 18%, respectively.
Alike Provenzano et al. we also found poor agreement between the
preventability ratings from front-line intensivist reviews when compared
to blinded chart review [2]. In 21 cases (45%) in which the intensivist
scored a preventable death all three reviewers scored these non-
preventable. This might partly be explained by additional information on
each patient's individual circumstances that cannot easily be deduced from
patients' charts. Using APACHE IV as selection criterion for in-depth
evaluation is insufficient while analysis of patients with an APACHE IV
based risk of mortality below 20% showed that only 4 of these deaths
(8.3%) were considered potentially preventable [3].
Preventability of death evaluation of all inpatient deaths is
required either for quality improvement and/or by regulatory authorities.
A quick and efficient method with high response rates from front-line
providers is feasible and may provide useful information for quality
improvement [4]. However, large inter-individual variations in response
and judgment exist and, therefore, this method apparently is insufficient
for benchmarking.
References:
1. Provenzano A, Rohan S, Trevejo E, et al. Evaluating inpatient
mortality: a new electronic review process that gathers information from
front-line providers. BMJ Qual Saf 2015;24:31-37.
2. Hayward RA, Hofer TP. Estimating hospital deaths due to medical errors:
preventability is in the eye of the reviewer. JAMA 2001;286:415-20.
3. Girling AJ, Hofer TP, Wu J, et al. Case-mix adjusted hospital mortality
is a poor proxy for preventable mortality: a moddeling study. BMJ Qual Saf
2012;21:1052-1056.
4. Dijkema LM, Dieperink W, van Meurs M, et al. Preventable mortality
evaluation in the ICU. Crit Care 2012;16:309.
I have recently returned from the Association of Simulated Practice in Healthcare 2014 conference in Nottingham and whilst there was privileged to hear and meet Professor Erik Hollnagel. He presented eloquently on his work relating to “From Safety I to Safety II” [1] which provided an excellent opening for the conference’s theme of “Changing Behaviours.” His work sparked much debate and reflection, part...
I have recently returned from the Association of Simulated Practice in Healthcare 2014 conference in Nottingham and whilst there was privileged to hear and meet Professor Erik Hollnagel. He presented eloquently on his work relating to “From Safety I to Safety II” [1] which provided an excellent opening for the conference’s theme of “Changing Behaviours.” His work sparked much debate and reflection, particularly by myself when presenting our simulation work related to the Duty of Candour. We opened with a discussion considering how the NHS was perceived by the general population of the UK. The conversation moved to the role of the media in driving the campaign for patient safety and openness.
The media has embraced the reports of a small number of high profile failings in the NHS, with the now daily reporting of another “failure” or “cover-up”. It is therefore understandable why a large proportion of the population do not trust the NHS and feel there is a closed and dishonest culture [2]. The media focuses on the Safety I premise of failures [1]. This is driving the destruction of the NHS’s reputation and the wellbeing of staff and patients by focusing on the minority of outcomes which are negative. In November 2013, our local Trust was reported to be the second worst general hospital in England for avoidable deaths [3]. A review of the data and response from the Trust identified that the news report was misleading and the data inaccurate, causing unnecessary anxiety amongst patients and staff [4]. Such media reports place extra strain on the healthcare system with reputational damage and effects on morale which effect the ability of that organisation to sustain required operations.
However, now 12 years later, the focus still remains on the serious errors, incidents and failures of the NHS. These events are still the minority of events, but the focus remains on what went wrong. As it is time for healthcare to focus on Safety II, should it not be the same for the media? By focussing on what goes right and the NHS's incredible ability to succeed under varying conditions, the media can celebrate the NHS and help to drive the next stage of safety improvement. It is time for
the media to also move from Safety I to Safety II thinking.
The discussion regarding media involvement in the NHS prompted me to consider this further and I read with great interest the 2002 paper published in BMJ Quality and Safety considering the role of the media in pushing patient safety forward as the priority [5]. There is no doubt that media involvement has benefitted the patient safety agenda, by acting as a “watchdog” to hold the medical profession accountable for improved safety and quality of care. This in turn has created a passionate group of healthcare professionals striving for excellence in care.
12 years later, however, the focus still remains on the serious errors, incidents and failures of the NHS. These events are still the minority of events, but the focus remains on what went wrong. As it is time for healthcare to focus on Safety II, should it not be the same for the media? By focussing on what goes right and the NHS’s incredible ability to succeed under varying conditions [1], the media can celebrate the NHS and help to drive the next stage of safety improvement. It is time for the media to also move from Safety I to Safety II thinking.
The difficulty will be in convincing the media of its role in the next stage of safety. It remains important for the NHS to be transparent, but a balance must be sought between the ongoing need for accurate reporting of serious problems and celebration of the NHS’s staff and its successes. In a recent well known report on health and healthcare service delivery [6], the UK ranked number one against ten other wealthy countries for overall healthcare (based on quality, access, efficiency and equity).
Professor Hollnagel defined resilience as the ability of the healthcare system to adjust its functioning to sustain operations under both expected and unexpected conditions [1]. The media must understand the complexity of the NHS and be aware of the potential for their reporting to inadvertently remove those parts of the healthcare system that have contributed to its resilience.
1) Hollnagel E. Safety I and Safety II: The Past and Future of Safety
Management. Ashgate: Surrey, United Kingdom
2) YouGov UK. One in two don’t trust the NHS. [Online] 2013. Available from: https://yougov.co.uk/news/2013/06/13/1-2-do-not-trust-nhs/ [Accessed 14th November 2014].
3) Adams S. How 3,500 hospital patients lost their lives due to surgical errors or staff who were too busy to treat them... in just TWELVE months. The Mail on Sunday. [Online] November 09 2013. Available from: www.dailymail.co.uk [Accessed 14th November 2014].
4) Nottingham University Hospitals NHS Trust. Response to Mail On Sunday coverage (avoidable deaths). [Online: media response] 2013. Available from: http://www.nuh.nhs.uk/media/1459425/response_to_mail_on_sunday_coverage.pdf [Accessed 14th November 2014].
5) Millenson ML. Pushing the profession: how the news media turned patient safety into a priority. Qual Saf Health Care 2002; 11: 57–63.
6) Davis K, Stremikis K, Schoen C, Squires D. Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally. The Commonwealth Fund. 2014.
Dear Sir,
We read with interest the article by Schmidt et al. We applaud the authors for undertaking this large and complex study and for highlighting the great potential of newer technologies to improve patient care.
We hoped the authors could clarify some key issues. Firstly only one year's mortality data are used as a baseline comparator. Mortality fluctuates by year as this paper highlights, and can be affected by a large...
Dear Sir,
We read with interest the article by Schmidt et al. We applaud the authors for undertaking this large and complex study and for highlighting the great potential of newer technologies to improve patient care.
We hoped the authors could clarify some key issues. Firstly only one year's mortality data are used as a baseline comparator. Mortality fluctuates by year as this paper highlights, and can be affected by a large number of factors including how it is expressed (1). It is possible that the year chosen may have been an outlier that triggered the Trusts to actively invest in measures including EPSS. We would therefore be grateful if the authors could provide additional data on mortality in the years prior to the intervention. Were other strategies employed alongside EPSS? For example we understand University Hospital Coventry also called in Dr Foster Intelligence in 2007 to restructure practice (2).
As the paper uses only a historical comparator it is possible that a proportion of the improvement reflects the general national improvement in hospital mortality seen over the last decade (3). Do the authors have any data comparing their improvements with other Trusts of a similar size, case-mix, and similarly average HSMR (4)?
Interventions in healthcare are rarely without some adverse effects and as such we would be interested in any data collected on the potential negative aspects. These would include consequences of the increased workload for junior doctors and financial effect cost. Establishing that these were relatively minor would be very reassuring for other Trusts considering similar strategies.
While we agree that randomised controlled trials are complex, we suggest there is a strong rationale for them to disaggregate the benefit of EPSS from many confounding factors, and to inform clear health economic analysis.
Yours sincerely,
Dominick Shaw, John Blakey and Jamie Rylance
1 http://www.nejm.org/doi/full/10.1056/NEJMsa1006396#t=articleMethods
2 http://drfosterintelligence.co.uk/wp-content/uploads/2013/02/University-Hospitals-Coventry-Warwickshire-NHS-Trust-case-study.pdf
3 http://www.biomedcentral.com/1472-6963/13/216
4 http://drfosterintelligence.co.uk/wp-content/uploads/2011/11/Hospital_Guide_2011.pdf
We wish to congratulate Russ SJ et al. (1) for their excellent survey
investigating patients' views of the WHO safer surgery checklist.
The authors point out that the UK wide implementation of the
checklist has encountered some difficulties. Specifically, barriers
including checklist fatigue and difficulties in assembling the theatre
team are mentioned. Whilst we certainly agree with this, we wish to amend
the a...
We wish to congratulate Russ SJ et al. (1) for their excellent survey
investigating patients' views of the WHO safer surgery checklist.
The authors point out that the UK wide implementation of the
checklist has encountered some difficulties. Specifically, barriers
including checklist fatigue and difficulties in assembling the theatre
team are mentioned. Whilst we certainly agree with this, we wish to amend
the authors' catalogue of concerns by sharing our experience at Queen
Alexandra Hospital (QAH).
At QAH we operate a modified WHO safer surgery checklist to suit
local practice. The checklist is applied to every patient passing through
the theatre complex. During a routine audit we identified how an
apparently minor communication error fundamentally undermined the
checklist's safety function and placed our patients at risk.
Our venous thromboembolism (VTE) prophylaxis checkpoint reads 'VTE
prophylaxis considered?'. In practice however, this question is frequently
altered to 'Flowtron's on?' (Flowtron refers to the intermittent pneumatic
calf compression devices (IPCCD) used at QAH). The multiple meanings of
the word 'on' (either interpreted as 'on the patient' or 'switched on')
introduced ambiguity and a communication error. This incorrect use of the
checklist resulted in multiple patients having IPCCDs applied to their
calfs, yet the devices were never switched on and our patients were placed
at risk.
Our experience illustrates two important communication errors that
may undermine the checklist's safety function. Firstly, accurate and
unambiguous wording of each component of the checklist is essential. Words
with homonymous meanings should be avoided where possible. Secondly, each
checklist question must be verbalised accurately during the patient check
to avoid introducing errors.
The original WHO safer surgery checklist (2009) (2) limits such
potential error, as most questions are yes/no answerable. Any local
checklist modifications should aim to maintain this format. Introducing
words with homonymous meanings may lead to communication errors; undermine
the checklist's safety function and place patients at risk.
Reference:
1. BMJ Qual Saf. 2014 Jul 18. The WHO surgical safety checklist:
survey of patients' views. Russ SJ, Rout S, Caris J, Moorthy K, Mayer E,
Darzi A, Sevdalis N, Vincent C.
One example of our almost universal, daily inflicting of emotional harm on patients is our mis-labeling of the patient's presenting problem as the 'Chief Complaint'.
Years ago, an ICU patient said plaintively, "I'm not a complainer." after a bedside presentation is which that is just what he was called.
Let's call it the 'Presenting Problem'--in our talk and in our notes. It might contribute to a clima...
Marshall et al's (2014) paper was highlighted as an exemplar of stakeholder participation by a speaker at a recent public health research conference, held in Newcastle. Participants gave useful feedback about many of the core issues raised, which we reflect here.
Marshal et al's (2014) 'Researcher in Residence' models are suggested as a means of co-engaging academics and practitioners in the promotion of evide...
Dear Editor,
We read with interest your Editorial re the role of families in preventing avoidable harm in children (1).
Many public hospitals in Queensland Health in Australia have now implemented Ryan's Rule. When Ryan's parents were worried he was getting worse they didn't feel their concerns were acted upon in time. It was subsequently established that Ryan died from likely preventable causes. Ry...
We thank Dr. Iedema for highlighting that a gap exists in providers having the skillset to 'work smarter.' We agree that novel approaches to healthcare improvement are required that move beyond gadget-based solutions and that require a new set of skills of providers and provider organizations. The suggestion of video taping one's performance to review how the system (and its participants) currently operates and reflect...
The Hayes, Batalden and Goldmann piece is an important contribution to the debate about what exactly is practice improvement. Most practice improvement thinking is anchored in the 'innovation' paradigm, and this paradigm is predominantly 'gadget thinking'. Others' solutions are to be adopted here because they produce great outcomes elsewhere. Except now we have to figure out how we can get the gadget to work. Few commen...
Dear Editor,
Recently, Provenzano and colleagues found that an electronic tool collecting real-time clinical information directly from front-line providers was both feasible and useful to evaluate inpatient deaths [1]. These findings concur with our evaluation of the preventability of death using a simple electronic evaluation tool in our 46-bed adult Intensive Care Unit.
From September 2010 to Sept...
To the Editor
I have recently returned from the Association of Simulated Practice in Healthcare 2014 conference in Nottingham and whilst there was privileged to hear and meet Professor Erik Hollnagel. He presented eloquently on his work relating to “From Safety I to Safety II” [1] which provided an excellent opening for the conference’s theme of “Changing Behaviours.” His work sparked much debate and reflection, part...
We wish to congratulate Russ SJ et al. (1) for their excellent survey investigating patients' views of the WHO safer surgery checklist.
The authors point out that the UK wide implementation of the checklist has encountered some difficulties. Specifically, barriers including checklist fatigue and difficulties in assembling the theatre team are mentioned. Whilst we certainly agree with this, we wish to amend the a...
Pages