The issue of using UAPs to perform various medical duties has been
debated in the US as well. [Shostek K. Unlicensed Assistive Personnel:
Risk Management Considerations. J Healthc Risk Management 1998
Winter;18(1)] The 'role drift' described by M. McKenna is the result of a
shortage of professional and licensed caregivers like nurses and
technologists with college degrees. The performance of a task (su...
The issue of using UAPs to perform various medical duties has been
debated in the US as well. [Shostek K. Unlicensed Assistive Personnel:
Risk Management Considerations. J Healthc Risk Management 1998
Winter;18(1)] The 'role drift' described by M. McKenna is the result of a
shortage of professional and licensed caregivers like nurses and
technologists with college degrees. The performance of a task (such as
phlebotomy) and the understanding of the complexities of anatomy,
physiology, and human response to disease are not inseparable with
appropriate training and adequate oversight. In light of the need to focus
more on patient safety and less on "turf", teamwork in healthcare may be
the best approach.
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.
The no-child-left-behind program grades schools on the basis of test-
scores on their pupils. Waters, Lefevre, and Budetti have arguably
developed a far more valid and relevant measure of school-performance by
assessing malpractice-experience, as a function of medical school.
It seems anomalous, even negligent, that the authors would develop
data on which medical schools produce graduates wh...
The no-child-left-behind program grades schools on the basis of test-
scores on their pupils. Waters, Lefevre, and Budetti have arguably
developed a far more valid and relevant measure of school-performance by
assessing malpractice-experience, as a function of medical school.
It seems anomalous, even negligent, that the authors would develop
data on which medical schools produce graduates who experience little
litigation, more litigation and most litigation, but omit publication of
those specific data, according to named medical schools. Such publication
would doubtless be incendiary, among medical schools in the third tier and
maybe even in the second but wouldn't the authors best serve the public
interest by releasing such data, the better to inform prospective medical
students, in advance, of the risks to which they may expose themselves and
their future patients, if any, by accepting admission to certain medical
schools? Shouldn't there be a National Medical School Data Bank,
available to prospective medical students to enable them to choose medical
schools rationally?
If not, what justification is there for the National Practitioner
Data Bank, which keeps track of the dirt on physicians? A physician, if
"bad", may hurt a few patients. A medical school, if "bad", may produce
hundreds of "bad doctors" who may hurt thousands of patients.
The paper by Spiegelhalter is a valuable contribution to the
literature on presenting and displaying performance related outcome
measures.[1] It provides further methodological guidance on identifying
service providers whose performance falls outside control limits using
funnel plot methodology. When reporting on performance it is important to
have procedures in place which should be followed when...
The paper by Spiegelhalter is a valuable contribution to the
literature on presenting and displaying performance related outcome
measures.[1] It provides further methodological guidance on identifying
service providers whose performance falls outside control limits using
funnel plot methodology. When reporting on performance it is important to
have procedures in place which should be followed when outliers are
identified. These issues have been considered by the Paediatric Intensive
Care Audit Network (PICANet) who use the funnel plot methodology for
reporting risk-adjusted mortality from all paediatric intensive care units
(PICU) in England and Wales. Prior to producing these funnel plots for the
latest National Report, we issued a policy statement drawn up in
consultation with both our Clinical Advisory and Steering Groups.[2] In
summary, the PICANet policy (published in full at http://www.picanet.org.uk)
recognises that a PICU whose risk-adjusted mortality lies outside of the
control limits will be identified as having returned data that is markedly
different to the other PICUs. It is important to note that a PICU lying
outside the control limits is not sufficient evidence to suggest that it
has either markedly higher or lower mortality than other PICUs, merely
that the data they have returned is different to that of other PICUs. To
resolve why this data is different, PICANet will work with the units to
provide a satisfactory explanation, following the plan below
i) Review the data to investigate whether there are data driven
reasons for a PICU lying outside of the control limits (it is known that
risk-adjustment tools can be unreliable when a PICU has a particularly
high proportion of patients at either end of the bounds of the tool.)
ii) Review the quality of data supplied by the PICU. The quality of
the data is the PICUs’ responsibility. PICANet will provide feedback from
PICU data validation visits and central validation procedures. PICUs will
be expected to check the quality of individual data items.
iii) Plot the data quality indicators over time to identify whether
the anomaly can be traced to a certain data collection period.
iv) Plot the mortality ratio over time to identify whether the
anomaly can be traced to a certain data collection period.
v) Plot the observed mortality over time to identify whether the
anomaly can be traced to a certain data collection period.
vi) Plot the expected mortality over time to identify whether the
anomaly can be traced to a certain data collection period.
vii) Investigate the primary diagnoses for admissions to the PICU.
If the PICU has a very different diagnostic casemix when compared with
other PICUs this may suggest further refinements to the risk-adjustment
method are required.
viii) Produce a brief summary report of the above for the lead
clinician and Chief Executive at the PICU concerned together with an
invitation to meet in person to review the data with the PICANet team.
We believe having such a policy in place, clearly outlining our
interpretation and proposed actions before publication of such funnel
plots is vital to the chances of such information being accepted by staff
at the participating units and thus more likely to result in positive
actions being taken.
Yours sincerely,
Dr Gareth Parry, co-director of PICANet and reader in Health Services Research, University of Sheffield.
Dr Elizabeth Draper, co-director of PICANet and senior research
fellow. Department of Epidemiology and Public Health, University of Leicester
Prof. Patricia McKinney, co-director of PICANet and professor of
paediatric epidemiology. Paediatric Epidemiology Group, University of Leeds
References
1. Spiegelhalter DJ. Handling over-dispersion of performance
indicators. Qual Saf Health Care 2005; 14: 347-351.
2. Paediatric Intensive Care Audit Network. National Report
2003–2004. Universities of Leeds, Leicester and Sheffield, May 2005 (ISBN
0 85316 254 9).
In the Scandinavian countries we have a lot of discussions related to
how to publish quality improvement work, and process oriented writing
courses are ongoing. Therefore, this article comes on time. I really
agree with the authors that a quality improvement report has to follow
the IMRaD-model, and the Table 1 "Draft proposed guidelines for stronger
improvement evidence" and Table 2 are really helpfu...
In the Scandinavian countries we have a lot of discussions related to
how to publish quality improvement work, and process oriented writing
courses are ongoing. Therefore, this article comes on time. I really
agree with the authors that a quality improvement report has to follow
the IMRaD-model, and the Table 1 "Draft proposed guidelines for stronger
improvement evidence" and Table 2 are really helpful and understandable,
and will help me as a teacher and adviser of these courses. Thanks!!
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.
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.
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.
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.)
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.
Dear Editor
The issue of using UAPs to perform various medical duties has been debated in the US as well. [Shostek K. Unlicensed Assistive Personnel: Risk Management Considerations. J Healthc Risk Management 1998 Winter;18(1)] The 'role drift' described by M. McKenna is the result of a shortage of professional and licensed caregivers like nurses and technologists with college degrees. The performance of a task (su...
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...
Dear Editor,
The no-child-left-behind program grades schools on the basis of test- scores on their pupils. Waters, Lefevre, and Budetti have arguably developed a far more valid and relevant measure of school-performance by assessing malpractice-experience, as a function of medical school.
It seems anomalous, even negligent, that the authors would develop data on which medical schools produce graduates wh...
Dear Editor,
The paper by Spiegelhalter is a valuable contribution to the literature on presenting and displaying performance related outcome measures.[1] It provides further methodological guidance on identifying service providers whose performance falls outside control limits using funnel plot methodology. When reporting on performance it is important to have procedures in place which should be followed when...
Dear Editor,
In the Scandinavian countries we have a lot of discussions related to how to publish quality improvement work, and process oriented writing courses are ongoing. Therefore, this article comes on time. I really agree with the authors that a quality improvement report has to follow the IMRaD-model, and the Table 1 "Draft proposed guidelines for stronger improvement evidence" and Table 2 are really helpfu...
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,
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,
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,
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,
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...
Pages