The authors of the article 'Perceived Causes of Prescribing Errors by
Junior Doctors in Hospitals' published in the BMJ Quality & Safety on
30 October 2012 report that "the main task factor identified was poor
availability of drug information on admission (often out of hours)" and
"Systems which should aid prescribers were not always available (e.g. the
Emergency Care Summary was available, but the doctor did not have...
The authors of the article 'Perceived Causes of Prescribing Errors by
Junior Doctors in Hospitals' published in the BMJ Quality & Safety on
30 October 2012 report that "the main task factor identified was poor
availability of drug information on admission (often out of hours)" and
"Systems which should aid prescribers were not always available (e.g. the
Emergency Care Summary was available, but the doctor did not have a
password for it)". The article postulates that had the information
contained in the Emergency Care Summary (ECS) been available, it would
have led to a decrease in errors.
The ECS is a national system of shared electronic records in Scotland
which enables up to date prescribing information from Primary Care systems
to be available to clinicians working in unscheduled care i.e. Out of
Hours, Ambulance, Emergency Rooms and Acute Receiving Units(1). It was
designed to improve the information available when GP practices are
closed. At the time of the study, in 2011, ECS was not available for
junior doctors dealing with scheduled admissions in secondary care.
The lack of access to ECS in secondary care has been identified as a
critical patient safety gap and plans have been made to address this. New
developments to make the medication information in ECS available for all
patients in hospitals and out patients are underway. In 2011, a pilot
project in Lanarkshire reported(2) that the use of ECS for medicines
reconciliation in Medicine for the Elderly, Orthopaedic admissions and
Surgical day cases was found to be helpful by all users. A review of 31
cases found 119 discrepancies, between medicines information in ECS and
the referral letter, an average of 5 per patient, as the average length of
time between referral and pre-assessment was 110 days. The ECS records
were accessed by nursing staff and pharmacists carrying out medicines
reconciliation and was felt to be so beneficial that it was agreed to
extend the use of ECS within secondary care using the Clinical Portals(3)
to provide secure identity and event based governance(4).
The article states that "problems with inadequate quality medicines
information at admission to hospital were highlighted. It is
disappointing to see that measures such as the ECS which have been
designed to tackle this very issue by providing an up to date list of
patient's medicines are not working (many doctors said that they did not
have access to the Emergency Care Summary)" and we would like to correct
this statement as since it's inception the ECS was specifically designed
to improve care Out of Hours and was not available to hospital doctors for
planned admissions. Medicines reconciliation (a process by which the most
recent and accurate sources of information are used to create a full list
of medicines for a patient) has been a major priority for the Scottish
Patient Safety Programme and they have helped to make the case for
extending use of ECS for this purpose.
Significant developments are underway to extend access to ECS for all
clinical users and eHealth developments such as the Clinical Portals will
mean that ECS accounts and separate passwords will not be required in the
longer term.
Dr Libby Morris, eHealth Clinical Lead, Scottish Government Health
and Social Care Directorate and GP, Hermitage Medical Practices, 5
Hermitage Terrace, Edinburgh, EH10 4RP
Dr Ian M Thompson, Chair, Emergency Care Summary Service Board and
GP, East Linton Surgery, Station Road, East Linton, East Lothian, EH40 3DP
Jonathan Cameron, Programme Manager/ Interim Head of Project
Management, National Information Systems Group, NHS National Services
Scotland, Gyle Square, 1 South Gyle Crescent, Edinburgh EH12 9EB
Conflict of Interest:
LM and JC were responsible for managing the ECS as a development project. IMT is the clinical chair for ECS as a business as usual service.
We read the study by Durani et al (1) and the accompanying editorial
(2) with great interest. Aspiring to engage junior doctors in the safety
and quality movement is a noble aim but in doing so it is essential to
consider the influences of both the formal (explicit) curriculum and the
informal ('hidden') curriculum on doctors in training. We feel that whilst
Durani et al's questionnaire may be useful to chart temporal tre...
We read the study by Durani et al (1) and the accompanying editorial
(2) with great interest. Aspiring to engage junior doctors in the safety
and quality movement is a noble aim but in doing so it is essential to
consider the influences of both the formal (explicit) curriculum and the
informal ('hidden') curriculum on doctors in training. We feel that whilst
Durani et al's questionnaire may be useful to chart temporal trends in
junior doctors' knowledge and attitudes in patient safety, we would
caution against using subtle differences uncovered in trainees' responses
to inform the subsequent development of educational interventions. To do
so risks 'over-engineering' approaches to patient safety education and
neglecting the basics.
Our experience of implementing sustainable patient safety training
across a Foundation School ('Lessons Learnt: Building a Safer
Foundation')(3) has revealed two core ingredients for engaging junior
doctors in safety and quality improvement - training providers as a
minimum must ensure i) a safe environment for junior doctors to raise and
act on safety concerns and ii) basic instruction and opportunities in
patient safety and quality improvement for all junior doctors.
First and foremost, we argue that in order to engage junior doctors
in safety improvement, above all, they need to feel safe in the
environment within which they work. Whilst informal discussions of safety
and quality issues by junior doctors are commonplace in the 'Doctors'
Mess' and at other social gatherings, structured and protected
opportunities to do so within teaching programmes are severely lacking.
Moreover, whilst leadership and quality improvement schemes described
by Lemer et al(2) are laudable, they invariably appeal to a self-selected
group and are not always accessible to all. In the UK, latest guidance by
the General Medical Council emphasises the duty of doctors in raising and
acting on concerns about patient safety(4) and that leadership and
management is a core role of all doctors,(5) not reserved for the
privileged few. To ensure equity of opportunity and to fulfil the
regulator's standards we need to ensure the provision of basic training
and opportunities for junior doctors across both the domains of patient
safety and leadership.
Through providing basic instruction in patient safety and integrating
facilitated case-based discussions of patient safety incidents (PSIs)
within the teaching programme, we have successfully created a springboard
for Foundation trainees' engagement in safety and quality improvement.(3)
Importantly, trainees are not passive recipients of the intervention,
rather active collaborators with trainee 'Leads' at each site leading
local delivery of the programme and rising to the challenge of peer-
leadership. Whilst we do not claim that our programme is a panacea for
engaging junior doctors in quality and safety, we do feel it is an
important first step in promoting wide-scale clinical engagement in the
quality movement.
Conflict of Interest:
The authors are part of a team who developed, implemented and evaluated 'Lessons Learnt: Building a Safer Foundation' - a patient safety training programme for Foundation trainees in collaboration with the North Western Deanery and the Imperial Centre for Patient Safety and Service Quality. The programme won the BMJ Excellence in Healthcare Education Award 2012.
We were pleased to read the recent article by Greaves et al.1
outlining new methodological techniques to analyze patients' online
ratings of care. We agree with the authors that social media websites
represent a wealth of first-hand patient experiences with health and
healthcare, but have largely remained untapped by biomedical researchers -
especially to gain new insi...
We were pleased to read the recent article by Greaves et al.1
outlining new methodological techniques to analyze patients' online
ratings of care. We agree with the authors that social media websites
represent a wealth of first-hand patient experiences with health and
healthcare, but have largely remained untapped by biomedical researchers -
especially to gain new insights into how to improve clinical care. We
concur that "big data" techniques such as machine learning and natural
language processing can be extremely powerful to synthesize the large
amount of textual data on these sites.
However, our previous work has also suggested the importance of
traditional research methods applied to social media content. In
particular, qualitative analysis adds perspective to patients' online
dialogue where big data mining techniques perhaps cannot. In a
qualitative examination of primary care provider ratings on Yelp,2 we
analyzed 712 reviews of 455 doctors in four large urban areas (Chicago,
New York, Atlanta and San Francisco). We found that these provider ratings
often reflected the entire visit experience (i.e., parking, wait times,
front desk staff) rather than focusing solely on the clinical encounter
with the provider. Similarly, we recently qualitatively coded over 450
Twitter messages about cancer screening,3 and found that miscellaneous
tweets such as jokes or popular culture references could be distinguished
from the rich information about personal patient experiences with pap
smears or mammograms. In both instances, these nuances in the online
content may have been missed by applying data mining or natural language
processing alone.
Therefore, we advocate using mixed methods approaches to analyzing
social media content about health and healthcare experiences, as these
techniques are inherently complementary to one another. Big data
approaches allow researchers to examine millions of messages to uncover
trends and overall sentiment in the online content, as well as the
potential to rank the prevalence of specific discussion topics on social
media sites. However, in combination with qualitative analysis of a
carefully selected subsample of online content, the textual data can be
interpreted in light of additional context - allowing researchers both
breadth and depth in their work.
Moreover, not only should we aim to understand patient values and
preferences from the large amounts of publicly available dialogue on
social media, but we should also look to online social media as a means to
directly engage in this dialogue with patients. Because of the ease of
use and the speed of information dissemination, online social media
channels have become a cornerstone of everyday life, transforming the ways
that society shares ideas and beliefs, news, and information about
products and services among individuals and organizations. To be truly
patient-centered, healthcare providers and systems should play an active
role in communicating important health and healthcare messages through the
channels in which growing numbers of patients are already engaged.
Courtney R. Lyles, PhD & Urmimala Sarkar, MD, MPH
University of California San Francisco, Division of General Internal
Medicine
References
1. Greaves F, Ramirez-Cano D, Millett C, Darzi A, Donaldson L. Harnessing
the cloud of patient experience: using social media to detect poor quality
healthcare. BMJ quality & safety 2013.
2. Lopez A, Detz A, Ratanawongsa N, Sarkar U. What patients say about
their doctors online: a qualitative content analysis. Journal of general
internal medicine 2012;27(6):685-92.
3. Lyles CR, Lopez A, Pasick R, Sarkar U. "5 Mins of Uncomfyness Is Better
than Dealing with Cancer 4 a Lifetime": an Exploratory Qualitative
Analysis of Cervical and Breast Cancer Screening Dialogue on Twitter.
Journal of cancer education : the official journal of the American
Association for Cancer Education 2012.
We read with interest and agreement the editorial by Claire Lemur and
Fiona Moss(1). We very much concur with the point that we have to engage
the next generation of clinicians in quality improvement to ensure the
future of healthcare. In the article several leadership programmes are
mentioned and in addition we would add the NHS Medical Directors Clinical
Fellow Scheme(2). However all of these schemes involve a small...
We read with interest and agreement the editorial by Claire Lemur and
Fiona Moss(1). We very much concur with the point that we have to engage
the next generation of clinicians in quality improvement to ensure the
future of healthcare. In the article several leadership programmes are
mentioned and in addition we would add the NHS Medical Directors Clinical
Fellow Scheme(2). However all of these schemes involve a small number of
junior doctors rather than the whole. They represent the icing but it is
really the 'cake' that we must address.
In the Severn Deanery we have been running a structured, supported
quality improvement programme for the Foundation Year One (FY1s) doctors.
Starting four years ago in one hospital this now involves almost half of
the 280 FY1s in the deanery, and we plan to include all by 2015. The FY1s
chose the project that they feel is most relevant to them (i.e. weekend
handover, discharge summaries etc) and then run the project using The
Model for Improvement throughout their first year supported by mentors
(often who are junior doctors themselves). It has been hugely successful.
The only impediments to the further spread has been finding engaged
permanent staff with sufficient quality improvement knowledge to mentor
and support projects and a structure within the Hospital management to
facilitate and recognise the innovations that result; there has been no
problems with the enthusiasm and motivation from the juniors themselves.
It will only be by up skilling and engaging the 'cake' that we will be
able to prepare our future workforce for the task ahead.
1. Lemer C, Moss F. Patient safety and junior doctors: are we missing
the obvious? BMJ Qual Saf 2013;22(1):8-10.
2. Coltart CE, Cheung R, Ardolino A, Bray B, Rocos B, Bailey A, et
al. Leadership development for early career doctors. Lancet
2012;379(9828):1847-9.
In their paper 'The science of human factors: separating fact from
fiction', Russ et al present a description of the human factors (HF)
discipline, and discuss several cases where the science of HF has been
misapplied in healthcare [1].
On examining some of the examples of misapplication they provide, it
became apparent that in most cases the term 'human factors' was used to
describe factors relating to human...
In their paper 'The science of human factors: separating fact from
fiction', Russ et al present a description of the human factors (HF)
discipline, and discuss several cases where the science of HF has been
misapplied in healthcare [1].
On examining some of the examples of misapplication they provide, it
became apparent that in most cases the term 'human factors' was used to
describe factors relating to human behavior (e.g. communication), rather
than the scientific discipline [2, 3]. The research did not purport to
adopt a HF methodology or stance. Are these really misconceptions about HF
science?
Russ et al also provide examples of studies that refer to HF science
but emphasize the failures of people. They describe this research as
'counterproductive' but the work they cite adopted HF methods and exposed
some interesting aspects of human behaviour. For example, consultation
with clinicians revealed that user acceptance of technology was critical
for successful implementation of electronic medication management [4]. In
another study (of which I am an author), review of medication charts
revealed that misuse of an electronic prescribing system was associated
with the generation of unnecessary computerized safety alerts [5]. We
concluded that both system design and inadequate training may have
contributed to system misuse.
In their viewpoint, Russ et al, discuss training at some length and
provide an overview of where training is an appropriate versus
inappropriate HF technique for improving patient safety [1]. This
discussion interested me as their table (Table 1) referred to few studies
examining the effectiveness of training. They explain that training is not
appropriate if it is designed to address a type of error committed by
multiple users, as wide-spread error indicates a mismatch between system
design and human characteristics. Identification of mismatch between
design and human capabilities/limitations is at the crux of the HF
discipline and is undoubtedly an important undertaking. But is it not also
possible that all users received the same (ineffective) training, and so
all made the same types of error? In the same way, Russ at al suggest that
training is not appropriate when the goal is for individuals to stop using
technologies in the wrong way. But can it not be that correct use of the
system was not effectively demonstrated during training, and so users were
not aware that more efficient use was possible?
I agree with Russ et al in that additional training should only be
considered following an evaluation of system design, but what if design is
intended to break free from previous iterations, with the aim of
transforming or revolutionizing a task? There exists a tension between
designing systems that replicate current processes and so integrate
quickly into clinical practice versus designing systems that allow tasks
to be completed in more efficient ways, but which require a change in work
and cognitive processes and so necessitate a greater level of training.
Russ et al were quick to criticize previous research but by taking a
closer look there is value in all HF applications to healthcare.
References:
1 Russ AL, Fairbanks RJ, Karsh B-T, Militello LG, Saleem JJ, Wears
RL. The science of human factors: separating fact from fiction. BMJ
Quality & Safety. 2013 April 16, 2013.
2 Cahan MA, Starr S, Larkin AC, Litwin DM, Sullivan KM, Quirk ME.
Transforming the culture of surgical education: Promoting teacher identity
through human factors training. Archives of Surgery. 2011;146(7):830-4.
3 Rosenstein AH, O'Daniel M. Impact and Implications of Disruptive
Behavior in the Perioperative Arena. Journal of the American College of
Surgeons. 2006;203(1):96-105.
4 Abrams H, Carr D. The Human Factor: Unexpected Benefits of a CPOE
and Electronic Medication Management Implementation at the University
Health Network. Healthcare Quarterly. 2005;8(Sp):94-8.
5 Baysari MT, Reckmann MH, Li L, Day RO, Westbrook JI. Failure to
utilize functions of an electronic prescribing system and the subsequent
generation of 'technically preventable' computerized alerts. Journal of
the American Medical Informatics Association : JAMIA. 2012 Nov
1;19(6):1003-10.
Mackintosh et al. have made a useful contribution to the literature
about pregnant and parturient's safety (1). The purpose of an Early
Warning System (EWS) is to take action before deterioration that may
require multiorgan support in intensive care. The ethnographic technique
revealed many perceived benefits of a simple, graphic monitoring tool that
empowered escalation of concerns. The research team highlighted
incons...
Mackintosh et al. have made a useful contribution to the literature
about pregnant and parturient's safety (1). The purpose of an Early
Warning System (EWS) is to take action before deterioration that may
require multiorgan support in intensive care. The ethnographic technique
revealed many perceived benefits of a simple, graphic monitoring tool that
empowered escalation of concerns. The research team highlighted
inconsistencies in implementation of EWS, multiple competing charts for
antenatal, intrapartum, postnatal and high dependency care and also
resistance to medicalising normal birth. However, if EWSs do 'work'
(which may yet need proving), their value will also depend on the nature
and extent of problems which should not be understated.
The authors state "for every [maternal] death, nine women develop
major obstetric complications including haemorrhage, infection,
hypertensive disorders and thromboembolism". The RCOG reference cited is
itself in error as it reported the numbers of women in the UK utilising
critical care settings, (260 vs 14/ 100 000 maternities, a ratio of 19
high dependency and intensive care admissions to each death) (2). The
report explains how definitions of severe morbidity vary, but that the
number of major obstetric complications may be as high as 86-fold the
number of deaths (1 200/ 100 000 maternities) (2,3). EWSs may also have
an impact upstream on moderate morbidity with its commoner human and
financial costs.
References
1. Mackintosh N, Watson K, Rance S, Sandall J. Value of a modified
early obstetric warning system (MEOWS) in managing maternal complications
in the peripartum period: an ethnographic study. BMJ Qual Saf 2013;0:1-9.
doi:10.1136/bmjqs-2012-001781
2. Maternal Critical Care Working Group. Providing equity of critical
and maternity care for the critically ill pregnant or recently pregnant
woman. London: RCOG Press, 2011:4
In reply to Bewley's response to our paper, we acknowledge that a
number of studies have assessed the extent of major obstetric
complications as higher than that cited in the RCOG publication [1-5].
Definitions as well as rate estimation of maternal morbidity vary widely
across studies [1].
However, the premise of our paper was not to minimise the scale and
severity of the problem of maternal morbidity, but to explore t...
In reply to Bewley's response to our paper, we acknowledge that a
number of studies have assessed the extent of major obstetric
complications as higher than that cited in the RCOG publication [1-5].
Definitions as well as rate estimation of maternal morbidity vary widely
across studies [1].
However, the premise of our paper was not to minimise the scale and
severity of the problem of maternal morbidity, but to explore the logic
and perceived value of one particular safety solution, the MEOWS. In the
light of our findings, we still conclude that the complexity of managing
risk and safety within the maternity pathway, the associated opportunity
costs of MEOWS and variation in implementation call into question its
current role for routine use. We reiterate our belief that there is an
urgent need for further research to validate the MEOWS for the maternity
population.
References
1. Zhang WH, Alexander S, Bouvier-Colle MH, Macfarlane A; MOMS-B Group.
Incidence of severe pre-eclampsia, postpartum haemorrhage and sepsis as a
surrogate marker for severe maternal morbidity in a European population-
based study: the MOMS-B survey. BJOG 2005;112:89-96.
2. Maternal Critical Care Working Group. Providing equity of critical and
maternity care for the critically ill pregnant or recently pregnant woman.
London: RCOG Press, 2011
3. Waterstone M, Bewley S, Wolfe C. Incidence and predictors of severe
obstetric morbidity - a case control study. Br Med J 2001;322:1089-94
4. Brace, Victoria, Gillian Penney, and Marion Hall. Quantifying severe
maternal morbidity: a Scottish population study. BJOG: An International
Journal of Obstetrics & Gynaecology 2004;111:481-484
5. Zanconato, Giovanni, et al. Severe maternal morbidity in a tertiary
care centre of northern Italy: a 5-year review. Journal of Maternal-Fetal
and Neonatal Medicine 2012;25:1025-1028.
While Clinical Practice Guidelines (CPGs) have gained momentum to
inform evidence-based practices, less investment has been made to use CPGs
to support evidence-informed patient choice. The qualitative study by van
der Weijden et al. shows a consensual vision of the need for and benefice
of adapting CPGs into relevant patient versions to integrate patients'
preferences in clinical decision-making. While we agree with the...
While Clinical Practice Guidelines (CPGs) have gained momentum to
inform evidence-based practices, less investment has been made to use CPGs
to support evidence-informed patient choice. The qualitative study by van
der Weijden et al. shows a consensual vision of the need for and benefice
of adapting CPGs into relevant patient versions to integrate patients'
preferences in clinical decision-making. While we agree with the authors'
conclusions and the suggested so-called generic strategy in principle, we
would like to comment the proposed approach from the French perspective of
CPG development and shared decision-making (SDM). Doing so, we respond to
a major limitation stressed by Weijden et al. stemming from the fact that
the results reflect merely an anglo-saxon perspective.
Examination of non-adherence to practice guidelines of the French oncology
guidelines program "Standards, Options, Recommendations" (SOR) established
in 1993 by the National French Federation of Comprehensive Cancer
Centres,?1? revealed that diverging patient values and preferences may
hamper guideline adherence. This observation has led to two developments
we would like to share here: the development of patient versions of SOR
CPGs, and cancer patients' involvement in the development process of SOR
CPGs.
To improve patients' involvement in decision-making, participants
interviewed by the authors suggested translating CPG reports into lay
terminology useful to professionals and patients. Such an approach has
been implemented within the SOR program since 1999. It is based on an
interdisciplinary working group (clinicians, methodologists,
psychologists, linguist, anthropologist) and a triangulation of methods to
involve cancer patients, combining focus groups, semi-structured
interviews and postal surveys. We translated the SOR CPGs into patient
versions in more than twenty cancer sites. An innovative linguistic
approach was used to ensure that the information provided is adapted to
patients' health literacy. A list of generic questions that patients may
ask to health professionals was developed to support patient-centered
communication during the medical encounter and encourage SDM,?2?. As was
pointed out by Weijden et al., patient involvement in the development of
SOR patient versions let us to the awareness that SOR CPGs did not
adequately incorporate patient preferences, in particular the presentation
of treatment options, their benefits and risks. Consequently, we set up in
2003 a process to involve cancer patients in the development of these
guidelines,?3?. Our approach consisted in a cancer patient panel reviewing
the guideline draft and feeding back their comments and recommendations to
the guideline panel. Our approach allowed the patient group to formulate a
list of key recommendations from their perspective to be addressed in the
final guideline, and to point out situations most appropriate for SDM.
Patients stressed the importance of improved communication and information
to facilitate patient participation in the decision-making process.
Based on our experience, we hypothesize that CPGs can be adapted to
facilitate the integration of patients' preferences in clinical decision-
making. The French experience suggests that the consensual 'generic'
strategy proposed by the authors is applicable beyond the anglo-saxon
context of their study and provide a practical example of how the proposed
approaches could be translated within existing guideline programs. Recent
French institutional initiatives highlight a growing awareness of the need
to improve connection between CPGs, patient decision aids and SDM,?4-5?.
Developing and updating high quality CPGs and patient decision
support tools require substantial time, expertise and resources. We
support the author's view that it is preferable to adapt existing CPGs
rather than developing new patient decision support tools. Such approaches
may foster the integration of research evidence and individual preferences
in health care decisions, avoid duplication of effort and enhance
efficiency. Further research is needed to assess the impact on clinical
practice of such approaches.
Bibliography
1. Fervers B, Hardy J, Philip T. ? Standards, Options and
Recommendations ?. Clinical Practice Guidelines for cancer care from the
French National Federation of Cancer Centres (FNCLCC). Br J Cancer 2001;
84(Suppl2):1-92.
2. Fervers B, Leichtnam-Dugarin L, Carretier J, Delavigne V, Hoarau
H, Brusco S, Philip T. The SOR SAVOIR PATIENT project--an evidence-based
patient information and education project. Br J Cancer. 2003 Aug; 89 Suppl
1:S111-6.
3. Fervers B, Bataillard A, Carretier J, Kelson M. Involving cancer
patients in clinical practice guidelines (CPGs) development in a French
guidelines program: What are the key issues? Journal of Clinical Oncology,
2006 ASCO Annual Meeting Proceedings (Post-Meeting Edition).Vol 24, No 18S
(June 20 Supplement), 2006: 16029.
4. Haute Autorite de Sante (Health National Authority). Etat des
lieux. Patient et professionnels de sante : decider ensemble. Concept,
aides destinees aux patients et impact de la decision medicale partageee,
octobre 2013. http://www.has-
sante.fr/portail/upload/docs/application/pdf/2013-
10/12iex04_decision_medicale_partagee_mel_vd.pdf
5. Cnamts (National Health Insurance Fund). Ameliorer la qualite du
systeme de sante et maitriser les depenses : propositions de l'Assurance
maladie pour 2014. Rapport au ministre charge de la securite sociale et au
Parlement sur l'evolution des charges et des produits de l'Assurance
maladie au titre de 2014 (loi du 13 aout 2004), juillet 2013.
http://www.ameli.fr/fileadmin/user_upload/documents/cnamts_rapport_charges_produits_2014.pdf
With respect to the scientific article of Franklin et al. (BMJ Qual
Saf 2014;0:1-8.doi:10.1136/bmjqs-2013-002572) I would like to address two
further issues concerning the learning and reporting system in general as
well as defense strategies in order to prevent errors in administration of
intrathecal chemotherapy.
The amount of nine million incident reports in NHS is very impressive
when compared to other repor...
With respect to the scientific article of Franklin et al. (BMJ Qual
Saf 2014;0:1-8.doi:10.1136/bmjqs-2013-002572) I would like to address two
further issues concerning the learning and reporting system in general as
well as defense strategies in order to prevent errors in administration of
intrathecal chemotherapy.
The amount of nine million incident reports in NHS is very impressive
when compared to other reporting systems within European countries. NHS-
reports over a period of 11 years implicates that more than 2.000
incidents have to be sent per day by healthcare professionals to the
National Reporting and Learnings System (NRLS). According to published
data (1) for England and Wales more than 153.000 out of 1.45 million
incidents of the type "medication" were reported from Oct 2012 to Sep
2013. Severe harm or deaths were scored in 10.781 cases (0.7% per year).
Errors in administration of intrathecal chemotherapy have been reported in
38 times over a decade within NHS. Compared to the German Medicine (2)
(between 1995 to 2005 528 suspected adverse concerning vinca alkaloids) or
the European Medicine Agency (approximately 350 documented cases), the
number of reported events seems low within NHS. Nevertheless, reporting of
patient safety incidents is a subjective and voluntarily exercise and on a
very high level within NHS.
In many other European countries, homogenous reporting and learning
system are lacking so far. In Austria for example, a NLRS is implemented
and accessible for the public (3), whereas hospitals run various reporting
and learning systems without national coordination and evaluation. Within
four years of being online, in total 344 incidents were reported (4
reports per week) to the NLRS and thereof, 21% were scored implicating
therapeutic harm.
NHS is in a leading role concerning NRLS and the level of patient
safety culture with respect of reporting events as well as their open-
minded way in presenting statistics to the public is unique. Concerning
the data pool, NHS could support others in the development of guidelines
and patient safety practices in order to overcome the most prominent
hazards.
The authors presented a comprehensive list of defense strategies to
prevent vinca alkaloids errors. Furthermore, we suggest, in line with the
Evidence-Based Practice guideline (4), team trainings and in analogy to
the WHO-Surgical Safety Checklist a team-time-out before administration of
high-risk medication.
Author:
Name:Dr. Gerald Sendlhofer
Email:gerald.sendlhofer@medunigraz.at
Title/position:
1) Head
2) Scientific co-worker
Affiliations:
1) Department of Quality and Risk Management, University Hospital Graz, Graz, Styria, Austria
2) Division of Plastic, Aesthetic and Reconstructive Surgery, Medical University Graz, Styria, Austria
(1) http://www.nrls.npsa.nhs.uk/resources/collections/quarterly-data-
summaries/?entryid45=135253 (accessed 7 May 2014)
(2) http://www.akdae.de/Arzneimittelsicherheit/Bekanntgaben/Archiv/2005/791_20050603.html
(accessed 7 May 2014)
(3) https://www.cirsmedical.ch/austria/m_files/cirs.php?seitennr=cpFBeri
(accessed 7 May 2014)
(4) Schulmeister L. Preventing vincristine administration errors: does
evidence support minibag infusions? dOI: 10.1188/06.CJON.271-273
Stephanie et al has produced some very interesting observations about
the impact of electronic medical records on patient-doctor communication.
Recent investigations into the social care system in the light of child
abuse enquiries depicted that professionals spend far too much time on
making records rather than face to face meetings with families and
children. More trusts in the NHS are adapting paper light patient recor...
Stephanie et al has produced some very interesting observations about
the impact of electronic medical records on patient-doctor communication.
Recent investigations into the social care system in the light of child
abuse enquiries depicted that professionals spend far too much time on
making records rather than face to face meetings with families and
children. More trusts in the NHS are adapting paper light patient record
to improve efficiency and patient care. However, we conducted an audit in
a medium secure unit in Manchester to evaluate the efficiency of
electronic system and staff ability to access important clinical
documents. The results showed that time spent to find these documents was
significantly more on electronic record than the paper record which raises
questions about the efficiency of electronic patients record.
The authors of the article 'Perceived Causes of Prescribing Errors by Junior Doctors in Hospitals' published in the BMJ Quality & Safety on 30 October 2012 report that "the main task factor identified was poor availability of drug information on admission (often out of hours)" and "Systems which should aid prescribers were not always available (e.g. the Emergency Care Summary was available, but the doctor did not have...
We read the study by Durani et al (1) and the accompanying editorial (2) with great interest. Aspiring to engage junior doctors in the safety and quality movement is a noble aim but in doing so it is essential to consider the influences of both the formal (explicit) curriculum and the informal ('hidden') curriculum on doctors in training. We feel that whilst Durani et al's questionnaire may be useful to chart temporal tre...
January 31, 2013
To the editors:
We were pleased to read the recent article by Greaves et al.1 outlining new methodological techniques to analyze patients' online ratings of care. We agree with the authors that social media websites represent a wealth of first-hand patient experiences with health and healthcare, but have largely remained untapped by biomedical researchers - especially to gain new insi...
We read with interest and agreement the editorial by Claire Lemur and Fiona Moss(1). We very much concur with the point that we have to engage the next generation of clinicians in quality improvement to ensure the future of healthcare. In the article several leadership programmes are mentioned and in addition we would add the NHS Medical Directors Clinical Fellow Scheme(2). However all of these schemes involve a small...
In their paper 'The science of human factors: separating fact from fiction', Russ et al present a description of the human factors (HF) discipline, and discuss several cases where the science of HF has been misapplied in healthcare [1].
On examining some of the examples of misapplication they provide, it became apparent that in most cases the term 'human factors' was used to describe factors relating to human...
Mackintosh et al. have made a useful contribution to the literature about pregnant and parturient's safety (1). The purpose of an Early Warning System (EWS) is to take action before deterioration that may require multiorgan support in intensive care. The ethnographic technique revealed many perceived benefits of a simple, graphic monitoring tool that empowered escalation of concerns. The research team highlighted incons...
In reply to Bewley's response to our paper, we acknowledge that a number of studies have assessed the extent of major obstetric complications as higher than that cited in the RCOG publication [1-5]. Definitions as well as rate estimation of maternal morbidity vary widely across studies [1]. However, the premise of our paper was not to minimise the scale and severity of the problem of maternal morbidity, but to explore t...
While Clinical Practice Guidelines (CPGs) have gained momentum to inform evidence-based practices, less investment has been made to use CPGs to support evidence-informed patient choice. The qualitative study by van der Weijden et al. shows a consensual vision of the need for and benefice of adapting CPGs into relevant patient versions to integrate patients' preferences in clinical decision-making. While we agree with the...
With respect to the scientific article of Franklin et al. (BMJ Qual Saf 2014;0:1-8.doi:10.1136/bmjqs-2013-002572) I would like to address two further issues concerning the learning and reporting system in general as well as defense strategies in order to prevent errors in administration of intrathecal chemotherapy.
The amount of nine million incident reports in NHS is very impressive when compared to other repor...
Stephanie et al has produced some very interesting observations about the impact of electronic medical records on patient-doctor communication. Recent investigations into the social care system in the light of child abuse enquiries depicted that professionals spend far too much time on making records rather than face to face meetings with families and children. More trusts in the NHS are adapting paper light patient recor...
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