141 e-Letters

  • The Problem with Root cause analysis
    Siti Hosier

    I read with interest the article by Peerally et al (1) on 'The problem with root cause analysis'. I reflected on the recent cases that happened at Royal North Shore Hospital and Sydney Hospital (2,3,4) which led me to consider which investigative tool is best applied to different incidences and identified risks. The use of appropriate tools and involvement of key stakeholders are crucial elements to a successful investig...

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  • Black box medicine: a structured approach to organisational reflection on major maternal morbidity as a tool for effective organisational learning
    Alexander Davey
    Editor - Professor Knight(1) highlights a serious problem with systems of organisational learning in maternity care that is endemic across a variety of acute care settings in the NHS. I write to share my experience with a trainee based structured case note review method so other organisations and patients may benefit from what I refer to as a black box medicine (BBM) approach to major maternal morbidity. Trainee based mixed expl...
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  • Worthless Statistics in search of Meaningful Conclusion
    Louise B Andrew

    It appears that these authors believe that variability in the disciplinary rates between states is something that indicates a lack of quality and/or a lack of uniformity of safety measures.

    Nothing could be further from the truth.

    There are many more reasons affecting a state's disciplinary rates than those controlled for in the study. For just one glaringly obvious example, in certain states and i...

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  • Improving safety culture to reduce adverse events
    Girish Swaminathan

    Reynolds et al1 reported the impact of providing prescriber feedback in reducing prescribing errors. The authors have concluded that reducing prescribing errors needs a multifaceted approach and feedback alone is not sufficient. Medication errors are often preventable and inappropriate prescribing is identified as an important contributing factor to medication errors.2 It is interesting to note that despite regular feedb...

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  • The contributions of pediatric hospitals to highly reliable healthcare
    Richard J. Brilli, MD

    To the Editor:

    In this article, the authors propose that little evidence exists in healthcare to show that application of Highly Reliable Organization (HRO) principles has resulted in significant or sustained improvement in performance. Further, they attribute the problem partially to under- recognizing the role of habit in the process. While we fully agree that forming habitual behavior is essential to creating...

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  • Why do we love to hate ourselves?
    Robert L Wears

    Dhaliwal's comment [1] on Zwaan et al [2] nicely refutes what has been called "the hypothesis of special cause" [3] - the notion that when things turn out wrong, the cognitive processes leading to that outcome must have been fundamentally different (ie, error-prone) from when they turn out right. Dhaliwal's argument recapitulates thinking that is over 100 years old; one of the early contributors to psychology, Ernst Mach, wr...

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  • Healthcare Complaints: a valid metric for quality of care?
    Adam M Ali

    I read with interest the paper by Gillespie and Reader presenting the Healthcare Complaints Analysis Tool (HCAT) (1). The authors suggest that the HCAT could be used "as an alternative metric of success in meeting standards" and as a way "to benchmark units or regions". However, this makes the assumption that the volume and strength of complaints received is an accurate reflection of the standard of care being delivered....

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  • Authors response: Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors
    Olivia Ferrandez Quirante

    To the Editor,

    We have read with great interest the article by Schiff G D et al.,1 in which 6.1% of errors reported to the United States Pharmacopeia MEDMARX reporting system were classified as being related to the computerized prescription order entry (CPOE) system, representing the third most frequently reported errors in this notification system.

    Similarly, in a study conducted in our hospital, appro...

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  • Statistical analysis of differences in turnover times among operating theatres
    Franklin Dexter

    Overdyk et al. used remote video auditing with real-time feedback in a surgical suite [1]. As part of their randomized trial clustered by theatre, they report less turnover times among "fast rooms," those generally including 3 or greater cases per day.

    Successive turnover times between scheduled cases within theatres on the same date tend to be correlated (e.g., caused by same surgeon, nurses, and anaesthetist)....

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  • Patient-centered bedside rounds-Exploring patient preferences before patient-centered care
    Naseema B Merchant

    Dear Editor,

    It was with great interest that we read the study of O'Leary et al published in the December issue of the journal and were quite surprised by their findings that patient centered- rounds had no impact on patients' perceptions of shared decision making, activation, and satisfaction with care.1

    Previous studies have shown that patients prefer their rounding team conduct rounds at the bedside...

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