The human element of adverse events.
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Australia↗
Biomedical subjects
C A Vincent
Publications and source records attributed to C A Vincent.
Nurses' responses to severity dependent errors: a study of the causal attributions made by nurses following an error.
Attribution theory attempts to understand how people explain events and their own role in them, particularly events which are unusual or unpleasant. Based on previous studies on attributions, it was suggested that nurses would make more external attributions (i.e. blaming others or the environment) following an error with a serious outcome than one with a non-serious outcome. This would in turn suggest that they might be less likely to respond constructively and learn from serious errors. Sixty nurses were approached for this study. They were divided into two groups. One group (30 subjects) completed a questionnaire on the responses to a description of an error with a non-serious outcome and the second group (also 30 subjects) responded to questions to an identical error but with a serious outcome. The findings from this study indicated that nurses behaved in an atypical manner in response to making an error. Although both groups of nurses tended to make slightly more internal attributions for the error, indicating that they are likely to take responsibility for their error, those nurses in the serious outcome condition blamed themselves more for the error. This may be due to the strong professional ethos which exists amongst nurses that expects them to take responsibility for their actions. This would inevitably include any error that they may make in the course of giving care. The conclusion that can be drawn is that nurses might be quite receptive to making constructive changes in their practice following an error, provided this situation is managed properly.
Humans↗
Control of floral homeotic gene expression and organ morphogenesis in Antirrhinum.
The development of reproductive organs in Antirrhinum depends on the expression of an organ identity gene, plena, in the central domain of the floral meristem. To investigate the mechanism by which plena is regulated, we have characterised three mutants in which the pattern of plena expression is altered. In polypetala mutants, expression of plena is greatly reduced, resulting in a proliferation of petals in place of reproductive organs. In addition, polypetala mutants exhibit an altered pattern of floral organ initiation, quite unlike that seen in loss-of-function plena mutants. This suggests that polypetala normally has two roles in flower development: regulation of plena and control of organ primordia formation. In fistulata mutants, plena is ectopically expressed in the distal domain of petal primordia, resulting in the production of anther-like tissue in place of petal lobes. Flowers of fistulata mutants also show a reduced rate of petal lobe growth, even in a plena mutant background. This implies that fistulata normally has two roles in the distal domain of petal primordia: inhibition of plena expression and promotion of lobe growth. A weak allele of the floral meristem identity gene, floricaula, greatly enhances the effect of fistulata on plena expression, showing that floricaula also plays a role in repression of plena in outer whorls. Taken together, these results show that genes involved in plena regulation have additional roles in the formation of organs, perhaps reflecting underlying mechanisms for coupling homeotic gene expression to morphogenesis.
Base Sequence↗
A common mechanism controls the life cycle and architecture of plants.
The overall aerial architecture of flowering plants depends on a group of meristematic cells in the shoot apex. We demonstrate that the Arabidopsis TERMINAL FLOWER 1 gene has a unified effect on the rate of progression of the shoot apex through different developmental phases. In transgenic Arabidopsis plants which ectopically express TERMINAL FLOWER 1, both the vegetative and reproductive phases are greatly extended. As a consequence, these plants exhibit dramatic changes in their overall morphology, producing an enlarged vegetative rosette of leaves, followed by a highly branched inflorescence which eventually forms normal flowers. Activity of the floral meristem identity genes LEAFY and APETALA 1 is not directly inhibited by TERMINAL FLOWER 1, but their upregulation is markedly delayed compared to wild-type controls. These phenotypic and molecular effects complement those observed in the tfl1 mutant, where all phases are shortened. The results suggest that TERMINAL FLOWER 1 participates in a common mechanism underlying major shoot apical phase transitions, rather than there being unrelated mechanisms which regulate each specific transition during the life cycle.
Arabidopsis↗
Learning from errors in nursing practice.
Little attention is paid to the issue of errors in nursing practice. Staff are reluctant to discuss or publicize them. However, as clinical audit and quality management become more important and established in the health service, there is now a greater need to investigate and monitor the incidence of errors. The purpose of this study was to examine the causes and consequences of errors as well as the potential for errors to initiate changes in practice. One hundred and twenty-nine nurses answered a 22-item questionnaire relating to an error they had made. Nurses reported that the most common causes of errors were lack of knowledge or information, work overload, stressful atmosphere and lack of support from senior staff. Nurses were found to have recourse to a number of coping strategies in the aftermath of the error. Accepting responsibility and planful problem-solving were found to lead to positive changes in practice, whereas distancing and self-controlling strategies were associated with defensive changes, particularly with a tendency not to divulge the error. The findings also showed that errors had the potential to effect learning. The study suggests the need for staff to be encouraged to accept responsibility for their error within the framework of support. Strategies should be developed so that errors can be managed in a more constructive manner.
Adaptation, Psychological↗
Cell lineage patterns and homeotic gene activity during Antirrhinum flower development.
BACKGROUND: Homeotic genes controlling the identity of flower organs have been characterized in several plant species. To determine whether cells expressing these genes are specified to follow particular developmental fates, we have studied the pattern of cell lineages in developing flowers of Antirrhinum. Each flower has four whorls of organs, and progenitor cells of these can be marked at particular stages of development using a temperature-sensitive transposon. This allows the cell lineages in the flower to be followed, as well as giving information about rates of cell division. RESULTS: We show here that, prior to the emergence of organ primordia, cells in the floral meristem have not been allocated organ identities. After this time, lineage restrictions arise between whorls, correlating with the onset of expression of genes that control organ identity. A further lineage restriction appears slightly later on, between the dorsal and ventral surfaces of the petal. Our results further suggest that the rates of cell division fluctuate during key stages of meristern development, perhaps as a consequence of meristem-identity gene expression. CONCLUSIONS: The patterns of lineage restriction and organ-identity gene expression in early floral meristems are consistent with some cells being allocated specific identities at about this stage of development. Plant cells cannot move relative to each other, so lineage restrictions in plants may reflect particular orientations and/or rates of growth at boundary regions.
Genes, Homeobox↗
Teaching communication skills to clinical students.
Seven years' experience in teaching communication skills to first year clinical students at St Mary's Hospital School of Medicine is described. The first component consists of a day during the introductory clinical course; this is divided into a lecture and small seminar groups and involves behavioural scientists and clinicians from many departments. The second component uses simulated patients and video feedback and takes place in small groups later in the year. Participation of the students through active critical discussion, role play, and interactive video feedback are important aspects in the success of the course. The methods have been refined through evaluation by students and tutors. This article aims to allow others, already running or considering such a course, to develop effective courses within the practical constraints of their own institutions.
Clinical Competence↗
The changing clinical experience of British medical students.
The UK National Health Service is undergoing fundamental reforms, which might have a detrimental effect on the training of doctors, not least with respect to the amount of clinical experience that medical students get. We compared the practical experience gained by two cohorts of students at medical schools throughout the UK, who had started their training in 1981 or 1986. The assessment was made by questionnaire at the end of their final clinical year. Experience of acute medical conditions, surgical operations, and practical procedures differed significantly between groups of medical schools, and showed a significant decline in the past five years. This decline in the clinical experience of medical students has coincided with the introduction of the health service reforms. We suspect that the university-based clinical education designed for a lifetime of change is in danger of being replaced by a dispersed clinical apprenticeship for current practice.
Analysis of Variance↗
Patients' experience of surgical accidents.
OBJECTIVE: To examine the psychological impact of surgical accidents and assess the adequacy of explanations given to the patients involved. DESIGN: Postal questionnaire survey. SETTING: Subjects were selected from files held Action for Victims of Medical Accidents. PATIENTS: 154 surgical patients who had been injured by their treatment, who considered that their treatment had fallen below acceptable standards. MAIN MEASURES: Adequacy of explanations given to patients and responses to standard questionnaires assessing pain, distress, psychiatric morbidity, and psychosocial adjustment (general health questionnaire, impact of events scale, McGill pain questionnaire, and psychosocial adjustment to illness scale). RESULTS: 101 patients completed the questionnaires (69 women, 32 men; mean age 44 (median 41.5) years. Mean scores on the questionnaires indicated that these injured patients were more distressed than people who had suffered serious accidents or bereavements; their levels of pain were comparable, over a year after surgery, to untreated postoperative pain; and their psychosocial adjustment was considerably worse than in patients with serious illnesses. They were extremely unsatisfied with the explanations given about their accident, which they perceived as lacking in information, unclear, inaccurate, and given unsympathetically. Poor explanations were associated with higher levels of disturbing memories and poorer adjustment. CONCLUSIONS: Surgical accidents have a major adverse psychological impact on patients, and poor communication after the accident may increase patients' distress. IMPLICATIONS: Communication skills in dealing with such patients should be improved to ensure the clear and comprehensive explanations that they need. Many patients will also require psychological treatment to help their recovery.
Accidents↗
Organizing an efficient trauma team.
A prospective analysis of 207 trauma patients, from three internationally recognized trauma centres, showed that trauma teams in which staff carry out allocated tasks simultaneously have the quickest resuscitation times. This finding was further tested by introducing these changes into a fourth centre. A comparison of resuscitation stage times was made in 26 patients before and 24 patients after the introduction of the organizational changes. Significant time reductions were found in all the stages, except the time taken to examine the patient. The time taken to complete the resuscitation was reduced by over half from 122 to 56 min. Significant time reductions applied even when variations in the type of patient, the team size or seniority of the team leader was taken into account. Recommendations for the organization of trauma teams are made.
Adult↗
Variation in trauma resuscitation and its effect on patient outcome.
There were significant differences in the time taken to resuscitate 257 trauma patients from four internationally recognized trauma centres. The fastest unit completed resuscitation in 15 min while the slowest took 105 min. This variation was not explained by differences in the type of patient dealt with, seniority of the team leader, or the number of personnel in the trauma team. Although there were significant differences between the units with regard to these parameters, they did not account for the resuscitation time variations. The average post-qualification time of the team leader at the fastest unit was 2 years. Although the slowest unit had the smallest trauma team (two people), larger numbers of personnel did not shorten resuscitation times. The time taken to carry out the ABC of the primary survey was significantly correlated with patient's physiological change in the resuscitation room (R = -0.63, P less than 0.0001 with systolic blood pressure; R = -0.68, P less than 0.01 with the revised trauma score). A multiple regression with survival as the dependent variable revealed that this time was also a predictor of the patient's eventual outcome (t = 3.18, P less than 0.005).
Adult↗
Obstetric accidents: the patient's perspective.
Cases from the files of Action for Victims of Medical Accidents which had resulted in stillbirth, perinatal or neonatal death and long term mental or physical handicap were reviewed. In 41 cases there was both a detailed letter from the parents and an independent review by a senior obstetrician. The reviewer's main criticisms were of inadequate fetal heart monitoring, lack of involvement of senior staff and inadequate records. The fetal heart trace was missing in 7 cases and over half of the remaining 34 traces available were misinterpreted or not acted on. In 17 cases junior doctors failed to recognize fetal distress and managed a delivery that they did not have the experience to deal with. In a further 6 cases, senior staff were called but did not come. Records were criticized for being incomplete, illegible or missing. In a few cases unjustified alterations appeared to have been made. Women reported that on some occasions staff ignored their worries, were unsympathetic and gave too little information. Some parents also experienced considerable difficulty in obtaining a clear explanation of the nature and cause of their child's condition.
Birth Injuries↗
Obstetric accidents: a review of 64 cases.
OBJECTIVE: To identify the causes of obstetric accidents. DESIGN AND SETTING: Analysis of case records at the Medical Protection Society's London office covering the five years 1982-6. SUBJECTS: Cases that had come to litigation which had resulted in stillbirth, perinatal or neonatal death, central nervous system damage to the baby, or maternal death and in which there was an opinion from a senior obstetrician consulted by the society. Of 147 cases reviewed, 64 met the criteria for the study. MAIN OUTCOME MEASURES: The principal findings of the expert reviewers. RESULTS: Three major topics of concern emerged common to most of the 64 cases. These were inadequate fetal heart monitoring, mismanagement of forceps, and inadequate supervision by senior staff. In 11 of the 64 cases cardiotocography was omitted, in 19 cases the trace was missing, in six cases the trace was unreadable, and in 14 of the remaining 28 cases signs of fetal distress went unnoticed or were ignored. In 31 cases forceps were used to aid delivery or were tried and abandoned in favour of caesarean section. In 16 cases two or more attempts to use forceps were made. Five infant deaths were directly attributed to mismanaged forceps. In 20 cases senior staff were criticised by the expert reviewer for failure to come to the labour ward. In many of these cases they may have given advice over the telephone, but the inadequacy of records made it impossible to tell. In these cases the labour and birth were managed by junior staff, usually a senior house officer. In six cases when senior staff did come they suggested that no action was needed. CONCLUSION: These few cases should not be dismissed as isolated incidents in obstetric practice in Britain. They reflect more general problems--namely, concerning the ability of junior doctors to interpret fetal heart traces accurately, their ability to use forceps, and the participation of senior staff in running a labour ward and delivery suite.
Adolescent↗
The treatment of tension headache by acupuncture: a controlled single case design with time series analysis.
A single case design, with time series analysis, was employed to evaluate the efficacy of acupuncture in the treatment of tension headache. Fourteen patients were given eight weekly treatments, four of true acupuncture and four of sham in random order. Mean pain in medication scores were reduced by 52% and 54% respectively at initial follow-up. Reductions in pain scores of over 50% were achieved by half the patients and the significance of these changes confirmed by time series analysis. The majority of patients maintained their gains at four month follow-up. True acupuncture was shown to be significantly superior to sham, demonstrating a specific therapeutic action, in four patients. In the remainder no difference was observed. Possible mechanisms for these effects are discussed. Acupuncture is a potentially valuable treatment for tension headache but further research is needed.
Acupuncture Analgesia↗
Research into medical accidents: a case of negligence?
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Accidents↗
The significance of needle placement site in acupuncture.
Traditional acupuncturists claim that correct needling of classical acupuncture loci is associated with a characteristic set of sensations usually referred to as 'Teh Chi'. The studies reported here examine this claim. In the first a multiple adjective sensation rating scale was developed and administered to 125 patients receiving acupuncture treatment. The results were subjected to principal components analysis and the first factor to emerge provided some support for the constellation of sensations corresponding to Teh Chi. In the second study the scale was used in a randomised controlled mixed single/double blind experiment in which 65 volunteers were stimulated at three classical and three non-classical (sham) needling sites by either a trained acupuncturist (single blind) or an anaesthetist (double blind). The results of the second study did not support the contention that the sensations of Teh Chi occur more frequently at classical acupuncture needling sites. The implications of the results for the practice of acupuncture are discussed.
Acupuncture Therapy↗
A controlled trial of the treatment of migraine by acupuncture.
A randomised controlled trial comparing true and sham acupuncture was conducted on 30 patients suffering from chronic migraine. Diary measures of headache and medication intake were recorded throughout the study, and measures of headache quality, anxiety, and pain behaviour were taken. The credibility of the true and sham treatment procedures was also assessed. True acupuncture was significantly more effective than the control procedure in reducing the pain of migraine headache. Posttreatment reductions in pain scores and medication of 43 and 38%, respectively, were recorded in the true acupuncture group and were maintained at 4-month and 1-year follow-up.
Acupuncture Therapy↗