I appreciated Shearer et al's recent article in BMJQS[1], it brings
to light the debilitating effects of ill-placed social and cultural
influences, and the professional hierarchies evident in all hospitals. The
issues identified from the research further validate the necessity for a
systems approach when dealing with clinical risk management[2]. That said,
mandating rapid response systems (RRS) as part of hospital protocol...
I appreciated Shearer et al's recent article in BMJQS[1], it brings
to light the debilitating effects of ill-placed social and cultural
influences, and the professional hierarchies evident in all hospitals. The
issues identified from the research further validate the necessity for a
systems approach when dealing with clinical risk management[2]. That said,
mandating rapid response systems (RRS) as part of hospital protocols
should not be so quickly dismissed as an ineffective avenue to improving
RRS effectiveness. It is not a new concept that workplace culture has much
to do with clinical efficacy and patient safety; in fact, Leape and
Berwick[3] pinpoint culture as a significant barrier to progress in
patient safety and highlight the necessity for dramatic changes to occur
as the next step to achieving higher standards. Unequal relationships
exist within the healthcare team, and inter-occupational hierarchies
between doctors and nurses impede the flow of information[4], as does the
seniority of doctors over their junior staff[5]. This element of fear that
is created by an institution's structure - fear of reprimand by senior
staff, fear of failure to meet expectations, and fear of judgement from
others, acts alongside a clinician's medical knowledge in determining
whether or not to call for help in poorly defined clinical situations, or
to activate the RRS protocol, even when the patient fulfils the defined
criteria. Standardisation of processes is an acceptable and widely
employed mechanism for the prevention of errors[6]. Sliding scale insulin
dosing and perioperative antibiotic protocols were adopted by institutions
to produce significant improvements in patient safety, much of which
younger clinicians, like myself, take for granted these days. Following
the successful establishment of a rapid response team, it speaks for
itself that an effective way to ensure that patients are receiving a high
standard of care when their status is deteriorating is, not only to
educate and train staff on the RRS, but also to make such a protocol
compulsory.
At present, readily available and easily identifiable criteria exist
to guide the management of specific diseases, and to minimise variations
in clinical judgement within an institution. A mandated RRS protocol would
provide a similar opportunity to remove the pressure of judging the risk
involved in tricky clinical situations and the fear of repercussions
associated with initiating the call. I imagine, like those sliding scales
and antibiotic protocols, once implemented, a compulsory RRS protocol
would seem like second nature. Explicit criteria for determining when one
needs help and how to access that help, may serve as a means to
effectively overcome the negative implications of workplace culture, as
well as inter- and intra- professional hierarchies[4].
1. Shearer B, Marshall S, Buist MD, et al. What stops hospital
clinical staff from following protocols? An analysis of the incidence and
factors behind the failure of bedside clinical staff to activate the rapid
response system in a multi-campus Australian metropolitan healthcare
service. BMJ Qual. Saf.2012;21:569-75.
2. Kohn CT, Corrigan JM, Donaldson MS. Chapter 8: creating safety
systems in health care organizations. To err is human: building a safer
health system. Washington, DC: National Academy Press 1999:134-174.
3. Leape LL, Berwick DM. Five years after To Err Is Human, what have
we learned? JAMA. 2005;293(19):2384-90
4. Mackintosh N, Sandall J. Overcoming gendered and professional
hierarchies in order to facilitate escalation of care in emergency
situations: the role of standardised communication protocols. Soc Sci Med.
2010;71(9):1683-6
5. Stewart J. To call or not to call: a judgement of risk by pre-
registration house officers. Med Educ. 2008;42(9):938-44
6. Leape LL. Error in medicine. JAMA. 1994;272(23):1851-7
We read the article on discharge summaries by Mohta et al with
interest. We passionately believe that we must keep trying innovative
methods to improve the quality of this most important handover document of
care. Earlier this month, our audit to evaluate the extent to which
contents of all fields in the electronic discharge summary template are
completed with relevant information, revealed that the trainees had failed
to...
We read the article on discharge summaries by Mohta et al with
interest. We passionately believe that we must keep trying innovative
methods to improve the quality of this most important handover document of
care. Earlier this month, our audit to evaluate the extent to which
contents of all fields in the electronic discharge summary template are
completed with relevant information, revealed that the trainees had failed
to complete some of the most important fields in the template. We then
interviewed doctors at different seniority in our hospital to find the
reasons for such practice. We also interviewed GPs to confirm what they
want in these summaries. Based on the results, we now intend to implement
three interventions (1) Trainees will print random summaries completed by
them to do CbD (Case-based discussion) with their supervisors for their e-
portfolio. This will give them an opportunity for feedback from senior
consultants (2) We intend to put a large sticker on the top of the case
record for the clinicians to make note of any important clinical event as
it happens which should become part of the discharge summary at the time
of the patient discharge. Person completing the discharge summary will
make sure that all events on the sticker form part of the summary (3)
Formal training module on discharge summaries at the time of induction on
the first day when the trainee joins the Department. It will be
interesting to find the results of the closing loop results of this audit.
I appreciated seeing an introduction of analysis of means (ANOM) by
Mohammed and Holder. As stated in their article, the technique is not well
known, but nonetheless I would like to encourage people to learn this
useful graphical display to compare groups. I have been using this method
in healthcare improvement work (1,2) and would like to share a couple of
lessons learned over the years.
The proportion ANOM chart should...
I appreciated seeing an introduction of analysis of means (ANOM) by
Mohammed and Holder. As stated in their article, the technique is not well
known, but nonetheless I would like to encourage people to learn this
useful graphical display to compare groups. I have been using this method
in healthcare improvement work (1,2) and would like to share a couple of
lessons learned over the years.
The proportion ANOM chart should meet most of your needs, since first
continuous type data can be converted to a proportion. For example, length
of stay (LOS) greater than 2 days can be used in the proportion ANOM chart
to compare groups (such as hospitals or providers) versus using LOS in the
continuous ANOM chart. Secondly, the proportion ANOM chart is easier to
use since it is the p-chart (a statistical process control chart), which
people may be familiar with. The only difference between the ANOM for
proportions and the p-chart is the control limits on the ANOM are not set
at 3 sigma - they are adjusted to account for number of groups being
compared. The best reference I have seen on ANOM is in a book by
Balestracci & Barlow.(3)
Another issue with the ANOM chart is the denominator size - you need the
right size for these charts to be most helpful. A good rule of thumb is 5. If you are comparing LOS greater than 2 days across hospitals and
25% is the overall rate then each hospital will need to have 21 or more
patients (5/.25 = 20). If there were only 10 patients in each group, then
the control limits will be too wide and may not yield useful information.
Besides too few patients in the denominator, another issue is too many
patients. If your subpopulation of patients is 1,000, then you have 50
times more patients than needed and you may have many groups crossing the
limits, which most likely contains Type 1 errors and is also useless
information. The primary purpose of the ANOM chart is to find the hospital
(or whatever you are comparing) that is performing outside the system
result because there will be opportunity to learn from the hospital that
is performing beyond the others.
One last lesson to keep in mind is the ANOM chart can be somewhat useless
if you are analyzing rare events or a proportion that is less than 10%.
For example, mortality rate (MR) for a specific procedure is 1.5% and you
want to see if there is a difference across 15 hospitals; however, there
are on average 100 patients per year that have the procedure. Using the 5 rule, you would need 334 or more patients in the denominator so
you will need 3.3 years of data. You may have the data, but most likely
you will only find a low performer, which can be motivating information
for the low performing hospital but more useful information is finding a
hospital that is doing this well. If a hospital had 0% MR, then the ANOM
chart will not show the 0% crossing the lower limit with 334 patients in
the denominator. The hospital would need to have 2.5 times more patients
(835 with 0% MR) and then the result would be significantly different.
If ANOM is not in your analytical tool box, I would highly suggest
learning more about this method, since the graphical display does so
effectively what statistical process charts are suppose to do - point out
the difference between common and special cause variation.
1. Homa K. Analysis of means used to compare providers' referral
patterns. Quality Management in Health Care 16(3): 256-264, July/September
2007.
2. Homa K, Kirkland KB. Determining next steps in a hand hygiene
improvement initiative by examining variation in hand hygiene compliance
rates. Quality Management in Health Care 20(2):116-121, April - June 2011
3. Balestracci D, Jr., Barlow JL. Quality Improvement. Practical
Applications for Medical Group Practice. 2nd ed. Englewood, CO: Center for
Research in Ambulatory Health Care Adminstration; 1998.
There is a paucity of papers focused on the sustainability of
improvement projects. In addition, the authors and the VA are to be
congratulated on sharing what are less-than-positive results so we can all
learn.
The quality improvement collaborative (QIC) process is excellent in
raising awareness of issues, training staff in QI techniques and in
mobilising action to improve. With all methods there are some gain...
There is a paucity of papers focused on the sustainability of
improvement projects. In addition, the authors and the VA are to be
congratulated on sharing what are less-than-positive results so we can all
learn.
The quality improvement collaborative (QIC) process is excellent in
raising awareness of issues, training staff in QI techniques and in
mobilising action to improve. With all methods there are some gains and
losses. The positive contribution of the QIC process needs to be balanced
with the lack of deep behavioural or system change - and this matters when
it comes to sustainability. The continual focus on technical measurements
in QIC allows participants to displace the need for behavioural changes.
Also, because the process is team focused, rather than organisational
focused, system changes are difficult to make.
Just because sustainability drops off after the program, doesn't mean
it isn't a good program. It may, however, mean that to gain sustainability
additional parallel support is required or the QIC needs to be redesigned
in content and structure.
We welcome the recent Original Viewpoint paper by Foy et al1, titled
The role of theory in research to develop and evaluate the implementation
of patient safety practices. We strongly support the recommendations in
this paper, and in particular, the application of behavioural change
theory in the design, implementation and evaluation of Patient Safety
Practices (PSPs).
We welcome the recent Original Viewpoint paper by Foy et al1, titled
The role of theory in research to develop and evaluate the implementation
of patient safety practices. We strongly support the recommendations in
this paper, and in particular, the application of behavioural change
theory in the design, implementation and evaluation of Patient Safety
Practices (PSPs).
However, on reading this paper, one could be forgiven for believing
that the use of such behavioural theory as the basis for the design,
implementation and evaluation of PSPs is novel. Reference to the
application of the Theory of Planned Behaviour (TPB) in the paper, was
restricted to taking intra-oral radiographs, managing upper respiratory
tract infections with antibiotics and disclosure of dementia: hardly
mainstream PSPs.
We are therefore perplexed at the apparent 'blind spot' of the
authors for citing relevant research in this area. Pubmed and even a
simple Google search using search string "TPB and patient safety
behaviours" will produce original published work which has been omitted.
The first article in this Google search is a paper which explored the
use of TPB in understanding hand hygiene behaviour and design of
interventions to improve compliance2. We have been using such theory for
more than ten years, to design, implement and evaluate important PSPs
including the recent pivotal PSP of hand hygiene.2,3 As hand hygiene was
used as a core example of PSP by Foy et al1, we were left wondering why
such relevant and highly cited3 research was not included.
Another citation on page one of the Google search related to an
original research paper published in 2010 in Quality and Safety in Health
Care (the same journal now called BMJ Quality and Safety). This paper
titled Patient Safety Culture: factors that influence clinician
involvement in patient safety behaviours4, applied TPB to a range of
patient safety behaviours including incident reporting and speaking up
when witnessing a colleague making a mistake. This paper has for the
first time in the literature identified predictive factors for these PSPs,
establishing unique models for differing professional sub-groups such as
junior and senior doctors; junior and senior nurses; and, allied health
practitioners. Again, it is hard to understand why such research,
published in the same journal, was not cited.
For the past decade behavioural theory has been successful in
predicting patients' non compliant antiviral therapy to prevent wide-
spread resistance8 as well as other central public safety issues of the
time.5-9
Perhaps the root cause of the issues identified by Foy et al, is that
the focus has been on identifying an evidence base for what PSPs to
implement, rather than how best to change behaviour and practice. The
former, is founded in traditional biosciences, reductionist research
paradigms and pedagogy, wheras the latter is far more the domain of public
health, behavioural and social sciences. Perhaps if we were to re-state
the problem of patient safety as public health, then we would start to
employ the appropriate scientific endeavours to design, implement and
evaluate interventions.
Finally, we welcome the increased focus on behavioural theory driven
interventions in patient safety, and congratulate the authors and journal
for shining a light on this important issue. However, we believe that the
authors have been selective in their review of the relevant literature on
the use of behavioural theory applied to PSPs, both at a general level,
and in relation to specific examples in the paper.
1. Foy R, Ovretveit J, Shekelle PG, et al. The role of theory in research to develop and evaluate the implementation of patient safety practices. BMJ Qual Saf bmjqs.2010.047993Published Online First: 11 February 2011 doi:10.1136/bmjqs.2010.047993.
2. Whitby M, McLaws ML, Ross MW. Why healthcare workers don't wash their hands: a behavioural explanation. Infect Control Hosp Epidemiol 2006; 27:
484-492.
3. Whitby M, Pessoa-Silva CL, McLaws ML, Allegranzi B, Sax H, Larson E, Seto WH, Donaldson L, Pittet D. Behavioural considerations for hand hygiene practices: the basic building blocks. J Hosp Infect 2006; 65(1):1-8.
4. Wakefield J, McLaws ML, Whitby M, Patton L, Blake S. Patient Safety Culture: Factors that influence clinician involvement in patient safety behaviour. Quality and Safety in Healthcare 2010 Aug 19 (6): 585-91.
5. Begely K, McLaws ML, Ross MW, Gold J. Adherence behavior of patients on long term protease inhibitor therapy: insight for the treating clinician.
Clinical Psychologist 2008;12(1):9-17.
6. McLaws ML, Irwig LM, Oldenburg B, Mock P, Ross MW. Predicting intention to use condoms in homosexual men: an application and extension of the theory of reasoned action. Psychol Health 1996;11(5):745-55.
7. McLaws ML, Oldenburg B, Ross MW. Application of the Theory of Reasoned Action to measurement of condom use among gay men. In: The Theory of Reasoned Action: Its Application to AIDS-Preventive Behaviour. Terry DJ,
Gallois C, McCamish M (Eds). Chapter 10. Pergamon Press. Oxford, 1993.
8. Ross MW, McLaws ML. Attitudes towards condoms and the Theory of Reasoned Action. In: The Theory of Reasoned Action: Its Application to AIDS-Preventive Behaviour. Terry DJ, Gallois C, McCamish M (Eds). Chapter 5. Pergamon Press. Oxford, 1993.
9. Ross MW, McLaws ML. Subjective norms about condoms are better predictors of use and intention to use than attitudes. Health Educ Research 1992; 7 (3): 335-339.
Travaglia et al's recent paper in BMJQS[1] alongside their earlier
work[2] provides some valuable insights into research which has been carried
out on large-scale disasters and accidents. This type of work has the
potential to move patient safety away from a focus on individual error and
towards the adoption of a wider and more inclusive perspective on the
failure of whole health care systems such as hospital.[3] That sa...
Travaglia et al's recent paper in BMJQS[1] alongside their earlier
work[2] provides some valuable insights into research which has been carried
out on large-scale disasters and accidents. This type of work has the
potential to move patient safety away from a focus on individual error and
towards the adoption of a wider and more inclusive perspective on the
failure of whole health care systems such as hospital.[3] That said, it
is perhaps all the more surprising that their work appears to have
overlooked the contribution of one of the landmark studies of the origins
and preconditions of disaster, namely the late Barry Turner's work on Man-
Made Disasters.[4-6] Turner carried out a detailed analysis of 84
British accident inquiry reports from 1965-1975 across a range of
industries. One outcome from his analysis was a stage model of the factors
underlying failure and a description of the preconditions for disaster in
what Turner called the "incubation period" immediately prior to the
disaster. During the "incubation period" a chain of discrepant events, or
several chains of discrepant events, develop and accumulate unnoticed.
These types of events might include oversights, failure to follow safety
procedures or errors which go unnoticed. In combination these events raise
the potential for an accident or disaster to occur. Turner's work is also
important in terms of the stress it placed upon adopting a systemic
approach towards accidents and disasters. The systems approach emphasizes
the need to understand in fine detail the nature of organisational
processes and the how connections between these processes and other system
levels (e.g., individual, group) emerge, interact and consolidate over
time. A comparison between the generic disaster model described by
Travalgia et al. with Turner's work, both in terms of his stage model and
focus on causality across system levels would be a worthwhile future
undertaking and might help us go further towards learning from patient
safety disasters.
Competing interests
None.
References
(1) Travaglia JF, Hughes C, Braithwaite J. Learning from disasters to
improve patient safety: applying the generic disaster pathway to health
system errors. BMJQS 2011; 20:1-8.
(2) Hughes C, Travaglia JF, Braithwaite J. Bad stars or guiding
lights? Learning from disasters to improve patient safety. Qual Saf Health
Care 2010;19: 332-336
(3) Weick KE, Sutcliffe KM, Hospitals as cultures of re-enactment: a
re-analysis of the Bristol Royal Infirmary. California Management Review,
2003; 45:2, 73-84.
Most Intensive Care Units (ICU) collect comprehensive data relating
to patient demographics, diagnoses and complications and some use this
information to benchmark and guide quality improvement activities aimed at
improving patient outcomes and reducing iatrogenic complications. Ayas
et. al. are to be commended for using routine information they collect in
an attempt to identify trends and possible contributing factors t...
Most Intensive Care Units (ICU) collect comprehensive data relating
to patient demographics, diagnoses and complications and some use this
information to benchmark and guide quality improvement activities aimed at
improving patient outcomes and reducing iatrogenic complications. Ayas
et. al. are to be commended for using routine information they collect in
an attempt to identify trends and possible contributing factors to one of
the potential complications related to insertion of Central Venous
Catheters (CVCs), development of a pneumothorax. Their retrospective
review did not confirm their suspicions that the incidence of pneumothorax
would increase with the introduction of new trainees to their area, which
is surprising, however they have suggested that decreased supervision as
the ICU rotation progresses may contribute to this.
CVCs are widely used in ICUs around the world, and pneumothoraces are a
significant potential complication of insertion of CVCs into the internal
jugular and subclavian veins (SCV). There is high level evidence to
support the insertion of CVCs into neck veins, particularly the SCV, as
opposed to femoral veins to reduce the incidence of blood stream
infections that contribute to significant morbidity and mortality, and
increased length and cost of hospital stay.1
Sheretz et. al. demonstrated that providing targeted training for
physicians in relation to methods to reduce infection related to vascular
device insertion resulted in improved knowledge and retention that
translated into practice. In their study, compliance with evidence based
procedures improved and resulted in a reduction in the incidence of CVC
bloodstream infections. They provided a detailed cost-benefit analysis of
their training program that supports such an approach to improving quality
and safety of patient care.2
Ault described an approach to training inexperienced practitioners that
used tissue models for practice, the use of ultrasound devices, a focus on
use of large drapes and improved sharps handling that resulted in improved
accuracy and safety of CVC insertion.3 Ayas et. al. refer to the use of
ultrasound guidance to assist in CVC placement as being sporadic in their
study settings, which could contribute to the trends they are identifying,
however the evidence to support the routine use of such devices is to date
not strong.4
The only training method referred to by Ayas et. al. is supervision by
more experienced practitioners in the clinical field. Perhaps they could
consider introducing more formalized training, as described above, to
reduce the incidence of pneumothorax and other complications related to
CVC insertion for their patients. The routine data they are currently
collecting could assist in assessing the efficacy of such an approach.
Ros MacLeod, BN, Grad Cert CCN, Grad Dip Nursing, Nurse Unit Manager, ICU,
Western Health, Footscray, Australia, Ros.MacLeod@wh.org.au
References:
1. O’Grady, N. P., Alexander, M., Dellinger, E. P., Gerberding, J.L.,
Heard, S. O., Maki, D. G., Maur, H., McCormick, R. D., Mermel. L.A.,
Person, M. L., Raad, I. I., Randolph, A., Weinstein., R. A.. Guidelines
for the Prevention of Intravascular Catheter-Related Infections. National
Center for Infectious Diseases. 2002.
www.cdc.gov/mmwr/preview/mmwrhtml/rr5110al.htm
2. Sherertz, R. J., Ely, E., Wesley M. D., Westbrook, D. M., RN, Gledhill,
K. S., Streed, S. A., Kiger, B., Flynn, L., Hayes, S., Strong, S., Cruz,
J., Bowton, D. L., Hulgan, T. & Haponik, E. Education of Physicians-in
-Training Can Decrease the Risk for Vascular Catheter Infection. Annals of
Internal Medicine: 2000: 132(8): 641-648.
3. Ault, M. J. The Use of Tissue Models for Vascular Access Training:
Phase 1 of the Procedural Safety Initiative. Academic Emergency Medicine.
2007: 14(1):13.
4. Stone, M.B. Identification and correction guide wire malposition during
internal jugular cannulation with ultrasound. Journal of the Canadian
Association of Emergency Physicians. 2007:p(2):131.
It has been well recognized internationally that hospitals are not as
safe as they should be. In order to redress this situation, health care
services around the world have turned their attention to strategically
implementing robust patient safety and quality care program to identify
circumstances that put patients at risk of harm and then acting to prevent
or control those risks
In my hospital the patient safety program h...
It has been well recognized internationally that hospitals are not as
safe as they should be. In order to redress this situation, health care
services around the world have turned their attention to strategically
implementing robust patient safety and quality care program to identify
circumstances that put patients at risk of harm and then acting to prevent
or control those risks
In my hospital the patient safety program has been implemented for 10
months. During the implementation period, the team continuously
encouraging all the staffs for actively reporting. The self assessment
result for patient safety activities was 77% (using hospital accreditation
criteria). The team has 2 weekly meeting agenda for discussing and
reviewing the incident reporting.
During theses 10 months, the team has received 45 cases of incident
reporting. The members of team actively collect the data by interviewing
the medical staffs from various facilities.
Most of the cases are in category of “near miss”, and “adverse events”.
The data showed that most of the incident are related to drug/ blood
products and medical equipment. Root cause analysis of several cases
showed that inadequate communication and inappropriate team working are
the main causes of the incident.
The effort for promoting patient safety and reducing error
The team and hospital leader continuously encouraging the medical staffs
for incident reporting.
The interesting finding is 29% of the incident reporting come from the
patients and family.
The article from Dr. Wasson, et.al. is very interesting. The use of
information technology will make the reporting system easier, faster, and
enabling of early identification. The online system can sure that the
system will be working in 24 hours a day. Appropriate action can be taken
for preventing further injury. The other important thing is to educate the
patients and family for identifying the adverse events, and report the
adverse events immediately.
Recently Neuhauser and Dias raised an important question [1]: are
randomised clinical trials (RCT) necessary in quality improvement?
They conclude that “RCTs need to be embedded in generalized
replicatable theory. Otherwise it is a scientific house without
foundation” and argue that RCTs comparing drugs cannot be replicated for
two reasons: (1) after a decade or two the control arm has changed and (2)
replicati...
Recently Neuhauser and Dias raised an important question [1]: are
randomised clinical trials (RCT) necessary in quality improvement?
They conclude that “RCTs need to be embedded in generalized
replicatable theory. Otherwise it is a scientific house without
foundation” and argue that RCTs comparing drugs cannot be replicated for
two reasons: (1) after a decade or two the control arm has changed and (2)
replication may be considered unethical if the original trial showed a
difference. Thus it is tempting to draw the conclusion that the authors
suggest that RCT should not be used when the effect of a new drug is to be
tested.
Why is it so important that an experiment can be replicated? Say drug
B is shown to be superior to drug A, and later drug C is shown to be
superior to drug B. Then, who really cares whether the experiment
comparing drug A and B can be replicated or not?
The authors’ claim that RCTs cannot be replicated may be challenged.
If the conditions for the control arm has changed then the intervention
arm conditions are likely to have changed in parallel over time. Then we
expect to be able to replicate the findings. But we have no way of knowing
this. In fact, given that the same drug is used over the years, it is
unethical not to replicate the experiments regularly, according to
paragraph 6 in the introduction to the Helsinki Declaration
(www.wma.net/e/policy/b3.htm).
We agree with the authors that statistical process control (SPC) has
an important role to play in medicine [2]. But we feel that the use of SPC
for the comparison of drugs is quite risky due to the potential for the
introduction of all kinds of bias [2,3]. Another reason why SPC may be
inferior to RCTs is that the application of SPC requires the processes
studied to be brought in statistical control prior to the intervention
[2]. This may not be possible to achieve because the patient mix may vary
over time. It may be argued, then, that statistical risk adjustment may
take care of this problem. However, it is well known that this approach is
fraud with problems [2,3]. By contrast, the attainment of statistical
control is not an issue in the case of RCTs, precisely due to the random
assignment of patients to the intervention groups.
References
1. Neuhauser D, Dias M. Quality improvement research: are randomized
trials necessary? Qual Saf Health Care 2007; 16:77-80.
2. Winkel P, Zhang NF. Statistical Development of Quality in Medicine.
John Wiley and Sons Inc, 2007; 1 – 263.
3. Deeks JJ, Dinnes J, D’Amico R, Sowdon AJ, Sakarovitch C, Song F,
Petticrew M, Altman DG. Evaluating non-randomised intervention studies.
Health Technol Assess 2003;7:1-173.
We thank Dr. McCarthy for his thoughtful insights on the application
of situational awareness (SA) in medicine. We agree that physicians begin
with a limited amount of SA and often fail to maximize their SA using a
team approach. Because of the increasing complexity and acuity of care in
the outpatient setting, the risk of outpatient medical errors has
increased during the past several years.[1] Thus, t...
We thank Dr. McCarthy for his thoughtful insights on the application
of situational awareness (SA) in medicine. We agree that physicians begin
with a limited amount of SA and often fail to maximize their SA using a
team approach. Because of the increasing complexity and acuity of care in
the outpatient setting, the risk of outpatient medical errors has
increased during the past several years.[1] Thus, the use of SA in
outpatient care has become more critical than ever. Although physicians
function at times with a high degree of SA, they seldom continue to be
"aggressively skeptic" in the environment of outpatient care due to
factors such as fragmented communication, as Dr. McCarthy noted. In our
article we propose that achieving "team SA" could overcome some of these
obstacles. Team SA can act as a safety net for primary care physicians
"flying solo" and can be facilitated by a culture change in physician-physician communication.
We do acknowledge omission of a post-event debriefing in our
discussion. Nevertheless, we believe learning resulted from this case to
some extent. We discussed the case in detail at a traditional M&M
conference and communicated several lessons to the audience.
Unfortunately, as many physicians would agree, the quest to make systems improvements and policy changes based on isolated "stories" is not always successful.[2] Unlike aviation, medicine seeks evidence from randomized
controlled trials and other evidence-based literature to change health
care systems. With decreasing funding opportunities to support research
on medical error management, we hope that cases such as ours illustrate
the learning opportunities from other high-risk industries.
Hardeep Singh, MD MPH,
Laura A. Petersen, MD MPH,
Eric J. Thomas, MD MPH
No competing interests
References
(1) Phillips RL Jr, Bartholomew LA, Dovey SM, Fryer GE Jr, Miyoshi
TJ, Green LA. Learning from malpractice claims about negligent, adverse
events in primary care in the United States. Qual Saf Health Care 2004;
13(2):121-126.
(2) Steiner JF. The Use of Stories in Clinical Research and Health
Policy. JAMA 2005; 294(22):2901-2904.
I appreciated Shearer et al's recent article in BMJQS[1], it brings to light the debilitating effects of ill-placed social and cultural influences, and the professional hierarchies evident in all hospitals. The issues identified from the research further validate the necessity for a systems approach when dealing with clinical risk management[2]. That said, mandating rapid response systems (RRS) as part of hospital protocol...
We read the article on discharge summaries by Mohta et al with interest. We passionately believe that we must keep trying innovative methods to improve the quality of this most important handover document of care. Earlier this month, our audit to evaluate the extent to which contents of all fields in the electronic discharge summary template are completed with relevant information, revealed that the trainees had failed to...
I appreciated seeing an introduction of analysis of means (ANOM) by Mohammed and Holder. As stated in their article, the technique is not well known, but nonetheless I would like to encourage people to learn this useful graphical display to compare groups. I have been using this method in healthcare improvement work (1,2) and would like to share a couple of lessons learned over the years. The proportion ANOM chart should...
There is a paucity of papers focused on the sustainability of improvement projects. In addition, the authors and the VA are to be congratulated on sharing what are less-than-positive results so we can all learn.
The quality improvement collaborative (QIC) process is excellent in raising awareness of issues, training staff in QI techniques and in mobilising action to improve. With all methods there are some gain...
Dear Editor,
We welcome the recent Original Viewpoint paper by Foy et al1, titled The role of theory in research to develop and evaluate the implementation of patient safety practices. We strongly support the recommendations in this paper, and in particular, the application of behavioural change theory in the design, implementation and evaluation of Patient Safety Practices (PSPs).
However, on rea...
Travaglia et al's recent paper in BMJQS[1] alongside their earlier work[2] provides some valuable insights into research which has been carried out on large-scale disasters and accidents. This type of work has the potential to move patient safety away from a focus on individual error and towards the adoption of a wider and more inclusive perspective on the failure of whole health care systems such as hospital.[3] That sa...
Most Intensive Care Units (ICU) collect comprehensive data relating to patient demographics, diagnoses and complications and some use this information to benchmark and guide quality improvement activities aimed at improving patient outcomes and reducing iatrogenic complications. Ayas et. al. are to be commended for using routine information they collect in an attempt to identify trends and possible contributing factors t...
It has been well recognized internationally that hospitals are not as safe as they should be. In order to redress this situation, health care services around the world have turned their attention to strategically implementing robust patient safety and quality care program to identify circumstances that put patients at risk of harm and then acting to prevent or control those risks In my hospital the patient safety program h...
Recently Neuhauser and Dias raised an important question [1]: are randomised clinical trials (RCT) necessary in quality improvement?
They conclude that “RCTs need to be embedded in generalized replicatable theory. Otherwise it is a scientific house without foundation” and argue that RCTs comparing drugs cannot be replicated for two reasons: (1) after a decade or two the control arm has changed and (2) replicati...
Dear Editor,
We thank Dr. McCarthy for his thoughtful insights on the application of situational awareness (SA) in medicine. We agree that physicians begin with a limited amount of SA and often fail to maximize their SA using a team approach. Because of the increasing complexity and acuity of care in the outpatient setting, the risk of outpatient medical errors has increased during the past several years.[1] Thus, t...
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