The authors (1) have raised a very important issue relating to
recognition and management of a deteriorating patient. Over the years,
cases have been reported where outcome may have been better if
deterioration was recognized in time. Once recognized, an urgent response
by a qualified team could instigate immediate investigations and
management as warranted, possibly averting a poor outcome.
The authors (1) have raised a very important issue relating to
recognition and management of a deteriorating patient. Over the years,
cases have been reported where outcome may have been better if
deterioration was recognized in time. Once recognized, an urgent response
by a qualified team could instigate immediate investigations and
management as warranted, possibly averting a poor outcome.
Code blue calls or cardiac arrest teams (2) were first introduced in
1970, with the motive of initiating an urgent response to a deteriorating
patient. By definition, activation of this system occurred after an arrest
had occurred, so patient had no recordable pulse, blood pressure,
respiration and did not respond to noxious stimuli.
However, more gains were to be made by initiating this response
before the patient had reached a terminal stage. Based on research showing
that cardiac arrest usually follows a series of events, attempts were made
to identify these events so as to preempt an arrest before it actually
occurred. Medical emergency teams (MET) were a culmination of these
efforts.
MET responses, introduced circa 2000 include a critical care
registrar and nurse, among others. Any clinician caring for a
deteriorating patient is encouraged to activate the response though a
rapid response system and can expect help within minutes. Whilst the
concept of MET response is similar to that of cardiac arrest teams, a
fundamental difference is in the timing of initiating the response.
However, the MET response is also activated after a level of
deterioration has occurred. The quest continued to find alarm signs or
signals that indicate deterioration is likely to occur. Once again, the
presumption is that an earlier response, before deterioration has
occurred, should result in a better outcome.
Analysis of hospital admissions suggests an adverse outcome is likely
in about 10% of admitted patients (3). Improving the outcome further,
particularly for these 10%, has triggered a nationally coordinated
approach that is being overseen by the Australian Commission on Safety and
Quality in Health Care (ACSQHC).
A new paradigm as suggested by Jones et al (4) would be required to
drive this further improvement. The focus is now on early detection and
prediction of clinical deterioration, so urgent help can be sought even
before the situation actually worsens. Eight essential elements have been
identified and compiled into a package that is the effort of ACSQHC.
Despite differences, it was encouraging that this consensus statement was
ratified by all state health ministers in Australia (5). The package,
widely distributed throughout Australian hospitals, is hoped to improve
outcomes by encouraging early detection of deterioration, and calling for
help early.
These strategies, in addition to the "swimming between the flags"
observation chart and rapid response systems include many other
initiatives with focus on education as one of the essential elements.
Different educational programs and packages such as COMPASS and DETECT (5)
have been developed in Australia specifically to improve practice
regarding the recognition and response to clinical deterioration amongst
all staff.
References:
1. Hughes C, Pain C, Braithwaite J, Hillman K. 'Between the flags':
implementing a rapid response system at scale. BMJ Qual Saf 2014;23:714-
717
2. McGrath RB. In-hospital cardiopulmonary resuscitation -- after a
quarter of a century. Ann Emerg Med 1987; 16: 1365-1368.
3. Runciman W and Moller J. Iatrogenic Injury in Australia, A Report
prepared by the Australian Patient Safety Foundation for the National
Health Priorities and Quality Branch of the Department of Health and Aged
Care of the Commonwealth of Australia (2001) available from:
http://www.apsf.net.au/dbfiles/Iatrogenic_Injury.pdf (accessed September
2014)
4. Jones AD, Dunbar NJ and Bellomo R. Clinical deterioration in
hospital inpatients: the need for another paradigm shift. Med J Aust 2012;
196 (2): 97-100
5. Australian Commission on Safety and Quality in Health Care.
National consensus statement: essential elements for recognising and
responding to clinical deterioration. Sydney: ACSQHC, 2010. Available
from: http://www.safetyandquality.gov.au/wp-content/uploads/2012/02/Nat-
Consensus-Statement-PDF-Complete-Guide.pdf (accessed Sept 2014)
Dear Editor,
we would like to congratulate Russ et al. on their paper on the patients'
views of surgical checklists (SC). In their elegant work, the above
authors underlined that assessing the fidelity of the SC remains a
challenge, but demonstrated a high level of patient support for use of
checklists. They found that patients were surprised that SC was only a
recent introduction to surgical care. Moreover, the authors...
Dear Editor,
we would like to congratulate Russ et al. on their paper on the patients'
views of surgical checklists (SC). In their elegant work, the above
authors underlined that assessing the fidelity of the SC remains a
challenge, but demonstrated a high level of patient support for use of
checklists. They found that patients were surprised that SC was only a
recent introduction to surgical care. Moreover, the authors stressed that
the majority of patients agreed that they would like the SC to be used if
they were having an operation.
In our experience, we confirm that the value of SC does not lie in the so-
called Hawthorne effect, but in changing (improving!) the mental model. As
also documented in the field of aviation, most accidents tend to involve
non-technical skills (NTS) such as communications, leadership, conflict,
and flawed decision-making. The relationship between NTS and human error
has been extensively demonstrated.
In Aviation it is mandatory for pilots to read a checklist for every single
phase of flight.
Of course they know the checklists by heart, but what if....you are
stressed, the last leg of the day, distracted, with family problems?
Of course it may be that you don't need any checklist, but will you risk it?
Will you risk to take off from Toronto under snow knowing that pilots
didn't read any checklist because they know procedures by heart and
because statistics say it doesn't matter, and results are the same..?
We would like conclude that one of the effective barriers to error is
the surgery safety checklist and, believe it or not, we are sure that
pilots if going under surgery they would like to know that surgeon uses
appropriate checklists that day!
____________________________________________________________
Fabrizio Dal Moro is an Assistant Professor at the University of Padova,
expert on NTS.
Gianluigi Zanovello and Fabio Cassan are airline pilots in Italy:
Zanovello is a former "Frecce Tricolori" (italian acrobatic team) leader;
Cassan was fighter squadron commander (51' Stormo Aeronautica Militare
Italiana).
They teach at Practice simulation center in the medicine University
of Verona - Italy. There, surgeons can practice exactly like the pilots
and run-through not only the anatomy before the real procedure. There is
something else: get familiar with NTS and understand that communication,
decision making, teamwork, situation awareness are important as the
professional, and technical.
The editorial from Sheikh, Atun, and Bates is welcome in flagging up
a key issue in the context of England and the US. However, it is not a
new issue, and it is disappointing that they do not acknowledge prior and
concurrent work.
The need for, and challenges impeding, evaluation of health
information systems have been flagged up much earlier, e.g. Rigby 1999;
2001. Both the European Federation for Medical In...
The editorial from Sheikh, Atun, and Bates is welcome in flagging up
a key issue in the context of England and the US. However, it is not a
new issue, and it is disappointing that they do not acknowledge prior and
concurrent work.
The need for, and challenges impeding, evaluation of health
information systems have been flagged up much earlier, e.g. Rigby 1999;
2001. Both the European Federation for Medical Informatics (EFMI) and the
International Medical Informatics Association (IMIA) have groups which
have followed up this theme. Ammenwerth instigated a European workshop
which inspired a significant work programme (Ammenwerth et al, 2004), and
led to production of reporting standards adopted by the EQUATOR network
(Talmon et al, 2009)and guidelines (Nyk?nen et al, 2011) which have been
fully elaborated (Brender et al, 2013).
The specific dual challenges behind the editorial by Sheikh, Atun and
Bates are the penchant for politicians to decree policy outside their
technical knowledge in order to appear progressive, and the generic need
for evidence-based policy in health informatics. This latter too has
recently been addressed - generically by a dedicated edition of the IMIA
Year Book (S?rousi et al, 2013) which included a summary of the concerted
actions of a decade (Rigby et al, 2013); and in the context of developing
countries by WHO (2011) and through a joint WHO-IMIA Programme (IMIA,
2012).
Moving to evidence-based health informatics policy is vital for
effectiveness, efficiency, safety, and enhanced health care delivery and
outcomes. Such an approach faces challenges as it cuts across the
perceived autonomy of politicians, and the worrying scant regard for a
scientific evidence base of some sectors of the supplier industry, while
evaluation to produce the evidence continually faces impediments as
described. It is therefore vitally important that all innovators and
activists work collaboratively to progress the issues.
Michael Rigby
Rigby M (1999) Health Informatics as a Tool to Improve Quality in Non
-acute Care - New Opportunities and a Matching Need for a New Evaluation
Paradigm; International Journal of Medical Informatics, 56, 1999, 141-150.
Rigby M (2001.)Evaluation: 16 Powerful Reasons Why Not to Do It - And
6 Over-Riding Imperatives; in Patel V, Rogers R, Haux R (eds.): Medinfo
2001: Proceedings of the 10th. World Congress on Medical Informatics, IOS
Press, Amsterdam, 2001, 1198-1202.
Ammenwerth E et al (2004). Visions and strategies to improve
evaluation of health information systems: Reflections and lessons based on
the HIS-EVAL workshop in Innsbruck. International Journal of Medical
Informatics, 2004 Jun 30; 73(6):479-91.
Talmon J. et al (2009. STARE-HI - Statement on Reporting of
Evaluation Studies in Health Informatics; International Journal of Medical
Informatics; 78 2009, 1, 1-9.
Nyk?nen P. (2011). Guideline for good evaluation practice in health
informatics (GEP-HI); International Journal of Medical Informatics, 80,
815-827, 2011.
Brender J (2013). STARE-HI - Statement on Reporting of Evaluation
Studies in Health Informatics: explanation and elaboration. Applied
Clinical Informatics, 2013; 4: 331-358.
S?rousi B, Jaulent M-C, Lehmann CU (eds.) (2013). Evidence-based
Health Informatics - IMIA Yearbook of Medical Informatics 2013; 34-46,
Schattauer, Stuttgart, 2013.
Rigby M. et al (2013). Evidence Based Health Informatics: 10 Years of
Efforts to Promote the Principle - Joint Contribution of IMIA WG EVAL and
EFMI WG EVAL; in S?rousi B, Jaulent M-C, Lehmann CU. Evidence-based Health
Informatics - IMIA Yearbook of Medical Informatics 2013; 34-46,
Schattauer, Stuttgart, 2013.
WHO(2011)Call to Action on Global eHealth Evaluation - Consensus
Statement of the WHO Global eHealth Evaluation Meeting, Bellagio,
September 2011; available from http://www.healthunbound.org/content/call-
action-global-ehealth-evaluation
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.
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
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
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.
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 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.
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.
The authors (1) have raised a very important issue relating to recognition and management of a deteriorating patient. Over the years, cases have been reported where outcome may have been better if deterioration was recognized in time. Once recognized, an urgent response by a qualified team could instigate immediate investigations and management as warranted, possibly averting a poor outcome.
Code blue calls or...
Dear Editor, we would like to congratulate Russ et al. on their paper on the patients' views of surgical checklists (SC). In their elegant work, the above authors underlined that assessing the fidelity of the SC remains a challenge, but demonstrated a high level of patient support for use of checklists. They found that patients were surprised that SC was only a recent introduction to surgical care. Moreover, the authors...
The editorial from Sheikh, Atun, and Bates is welcome in flagging up a key issue in the context of England and the US. However, it is not a new issue, and it is disappointing that they do not acknowledge prior and concurrent work.
The need for, and challenges impeding, evaluation of health information systems have been flagged up much earlier, e.g. Rigby 1999; 2001. Both the European Federation for Medical In...
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...
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...
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...
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...
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 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...
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...
Pages